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Self-Assessment Test UI (D Which ofthe following is the most appropriate additional Item 6 D vt treatment to improve this patient's leg pain? A 57 year-old man is evaluated lbr a 2 month history of UI .D ttl (A) Cilostazol exertional chest pain. UI (B) Clopidogrel The physical examination. including vital signs. is normal. .D (C) Evolocumab Baseline ECG is normal. During treadmill stress testing, { .D (D) Pentoxi[zlline he der,elops 2 mm horizontal ST segment depression in UI (E) Vitamin B complex supplementation leads V, through Vo associated with chest pain that resolves u,ith rest. Coronary angiographic flndings include a 60'/,, distal left main bifurcation stenosis u'ith extension into

UI (D Which ofthe following is the most appropriate additional Item 6 D vt treatment to improve this patient's leg pain? A 57 year-old man is evaluated lbr a 2 month history of UI .D ttl (A) Cilostazol exertional chest pain. UI (B) Clopidogrel The physical examination. including vital signs. is normal. .D (C) Evolocumab Baseline ECG is normal. During treadmill stress testing, { .D (D) Pentoxi[zlline he der,elops 2 mm horizontal ST segment depression in UI (E) Vitamin B complex supplementation leads V, through Vo associated with chest pain that resolves u,ith rest. Coronary angiographic flndings include a 60'/,, distal left main bifurcation stenosis u'ith extension into tr Item 4 A 62 year old woman is er,aluated in the emergency depart the proximal left circumllex artery. There is an additional 80',L stenosis involvir-rg the bifurcation of the left anterior descending artery and large first diagonal branch. The right ment for acute chest pain that began 90 minutes ago. The chest pain lasted fbr 45 minutes and then subsided spon coronary artery is large and without signiflcant stenosis. tancously. 'lhe pain was located across the front of the Left ventriculogram shows global left ventricular dysfunc- chest, did not radiate, and was described as a dull ache. lt tion with a left ventricular ejection fraction of 42%. was associated with nausea, diaphoresis, and shortness of breath. Medical history is notable only for asthma treated Which ofthe following is the most appropriate management? with inhaled mometasone furoate. (A) Coronaryarterybypassgrafting On physical examination, blood pressure is 174184 mm Hg in both arms. pulse rate is 98,min, respiration rate is (B) Medicaltherapywithout revascularization 24tmin, and oxygen saturation is 957, with the patient (C) Myocardial viability testing breathing ambient air. Cardiac examination reveals an S., (D) Percutaneous coronan, intenention but is otherwise normal. Wheezing is present on pulmonary auscultation. An initial high sensitivity cardiac troponin level is Item 7 equivocal. D dimer measurement is normal. A 70 year old man is evaluated tbr fatigue and dyspnea with ECG shows sinus tachycardia with nonspecific S'l' exertion that have progressed over 1 year. He reports no chest '[' wave changes. pain. Medical history is significant for hypertension, hyper The estimated pretest probability of coronary artery lipidemia, and bilateral carpal tunnel syndrome. Medications disease is 9'lu. are losartan, hydrochlorothiazide. and atorvastatin. On physical examination, vital signs are normal. Cen Which of the following is the most appropriate diagnostic tral venous pressure is elel'ated. and crackles are heard at test? the lung bases. The remainder of the physical examination (A) Adenosine myocardial perfusion imaging is normal. (B) Cardiac magnetic resonance imaging Laboratory studies show a B type natriuretic peptide level of 6,10 pg,,ml (640 ngrL). (C) Coronary CT angiography An ECG is shown (top of next page). An echocardio (D)'l'ransthoracicechocardiography gram shows normal left ventricular (LV) cavity size and moderate concentric LV hypertrophy. The LV ejection frac tion is 507,. Valve structure and function are normal. Right Item 5 ventricular hypertrophy is present. cavity size is normal. An 18 year old man is evaluated for a heart murmur noted and function is normal. Estimated right ventricular systolic on a preparticipation sports examination. He remembers pressure is 40 mm Hg. being told about a murmur in the past, but he has had no prior testing or intervention. He is asymptomatic. without Which of the following is the most appropriate test? known medical problems, and takes no medications. (A) Cardiac magnetic resonance imaging with gadolinium On physical examination, vital signs are normal. The estimated central venous pressure is normal. Apical impulse contrast is normal, and a thrill is noted along the left sternal border. (B) Exerciseechocardiography A grade 4/6 holosystolic murmur is heard at the left sternal (C) Rigtrt and left heart catheterization border, obscuring the Sr. The remainder of the physical (D) Serum o galactosidase level examination is unremarkable. An ECG and chest radiograph are normal. Item 8 Which of the following is the most likely diagnosis? A 78 year old woman with progressive exertional dyspnea (A) Atrial septal defect and chest pain is evaluated fbr aortic valve replacement. Results show severe aortic stenosis in the absence of obstruc (B) Coarctation ofthe aorta tive coronary artery disease. Medical history is signiflcant (C) Patent ductus arteriosus lbr hypertension, chronic kidney disease (stage G3a), hyper (D) Ventricular septal def'ect lipidemia, COPD, and atrial fibrillation. Medications are

tr Item 4 A 62 year old woman is er,aluated in the emergency depart the proximal left circumllex artery. There is an additional 80',L stenosis involvir-rg the bifurcation of the left anterior descending artery and large first diagonal branch. The right ment for acute chest pain that began 90 minutes ago. The chest pain lasted fbr 45 minutes and then subsided spon coronary artery is large and without signiflcant stenosis. tancously. 'lhe pain was located across the front of the Left ventriculogram shows global left ventricular dysfunc- chest, did not radiate, and was described as a dull ache. lt tion with a left ventricular ejection fraction of 42%. was associated with nausea, diaphoresis, and shortness of breath. Medical history is notable only for asthma treated Which ofthe following is the most appropriate management? with inhaled mometasone furoate. (A) Coronaryarterybypassgrafting On physical examination, blood pressure is 174184 mm Hg in both arms. pulse rate is 98,min, respiration rate is (B) Medicaltherapywithout revascularization 24tmin, and oxygen saturation is 957, with the patient (C) Myocardial viability testing breathing ambient air. Cardiac examination reveals an S., (D) Percutaneous coronan, intenention but is otherwise normal. Wheezing is present on pulmonary auscultation. An initial high sensitivity cardiac troponin level is Item 7 equivocal. D dimer measurement is normal. A 70 year old man is evaluated tbr fatigue and dyspnea with ECG shows sinus tachycardia with nonspecific S'l' exertion that have progressed over 1 year. He reports no chest '[' wave changes. pain. Medical history is significant for hypertension, hyper The estimated pretest probability of coronary artery lipidemia, and bilateral carpal tunnel syndrome. Medications disease is 9'lu. are losartan, hydrochlorothiazide. and atorvastatin. On physical examination, vital signs are normal. Cen Which of the following is the most appropriate diagnostic tral venous pressure is elel'ated. and crackles are heard at test? the lung bases. The remainder of the physical examination (A) Adenosine myocardial perfusion imaging is normal. (B) Cardiac magnetic resonance imaging Laboratory studies show a B type natriuretic peptide level of 6,10 pg,,ml (640 ngrL). (C) Coronary CT angiography An ECG is shown (top of next page). An echocardio (D)'l'ransthoracicechocardiography gram shows normal left ventricular (LV) cavity size and moderate concentric LV hypertrophy. The LV ejection frac tion is 507,. Valve structure and function are normal. Right Item 5 ventricular hypertrophy is present. cavity size is normal. An 18 year old man is evaluated for a heart murmur noted and function is normal. Estimated right ventricular systolic on a preparticipation sports examination. He remembers pressure is 40 mm Hg. being told about a murmur in the past, but he has had no prior testing or intervention. He is asymptomatic. without Which of the following is the most appropriate test? known medical problems, and takes no medications. (A) Cardiac magnetic resonance imaging with gadolinium On physical examination, vital signs are normal. The estimated central venous pressure is normal. Apical impulse contrast is normal, and a thrill is noted along the left sternal border. (B) Exerciseechocardiography A grade 4/6 holosystolic murmur is heard at the left sternal (C) Rigtrt and left heart catheterization border, obscuring the Sr. The remainder of the physical (D) Serum o galactosidase level examination is unremarkable. An ECG and chest radiograph are normal. Item 8 Which of the following is the most likely diagnosis? A 78 year old woman with progressive exertional dyspnea (A) Atrial septal defect and chest pain is evaluated fbr aortic valve replacement. Results show severe aortic stenosis in the absence of obstruc (B) Coarctation ofthe aorta tive coronary artery disease. Medical history is signiflcant (C) Patent ductus arteriosus lbr hypertension, chronic kidney disease (stage G3a), hyper (D) Ventricular septal def'ect lipidemia, COPD, and atrial fibrillation. Medications are 126

Self-Assessment Test t €, F q, U! .ln vt va U! o UI rn o vl I d^ w lr! .t/f v:3 \,l ITEM 7

o vl I d^ w lr! .t/f v:3 \,l ITEM 7 amlodipine, atorvastatin, Iisinopril, metoprolol, apixaban, (C) lmplantable cardioverter deflbrillator furosemide, and an albuterol ipratropium inhaler. (D) Lisinopril Her Society of Thoracic Surgeons adult cardiac surgery risk score is consistent with high risk. Item 10 Which of the following is the most appropriate next step in A 43-year-old man is evaluated during a follow-up visit treatment? for heart failure with reduced ejection fraction (ejec- (A) Balloon aortic valvuloplasty tion fraction, 45%) and type 2 diabetes mellitus. He is (B) Continued medical therapy currently asymptomatic. Medications are metformin, (C) Surgical aortic valve replacement valsartan sacubitril, metoprolol, spironolactone, and atorvastatin. (D) Transcatheter aortic valve implantation On physical examination, blood pressure is 108/72 mm [{g and pulse rate is 64lmin. There is no S.,, jugular venous distention, or peripheral edema. tr Item 9 A 21 year old woman is evaluated in the hospital following Hemoglobin A," level is 6.9')i,.

amlodipine, atorvastatin, Iisinopril, metoprolol, apixaban, (C) lmplantable cardioverter deflbrillator furosemide, and an albuterol ipratropium inhaler. (D) Lisinopril Her Society of Thoracic Surgeons adult cardiac surgery risk score is consistent with high risk. Item 10 Which of the following is the most appropriate next step in A 43-year-old man is evaluated during a follow-up visit treatment? for heart failure with reduced ejection fraction (ejec- (A) Balloon aortic valvuloplasty tion fraction, 45%) and type 2 diabetes mellitus. He is (B) Continued medical therapy currently asymptomatic. Medications are metformin, (C) Surgical aortic valve replacement valsartan sacubitril, metoprolol, spironolactone, and atorvastatin. (D) Transcatheter aortic valve implantation On physical examination, blood pressure is 108/72 mm [{g and pulse rate is 64lmin. There is no S.,, jugular venous distention, or peripheral edema. tr Item 9 A 21 year old woman is evaluated in the hospital following Hemoglobin A," level is 6.9')i,. cardiac arrcst that occurrecl cluring a collegiate cross country Which of the following is the most appropriate additional race. She received cardiopulmonary resuscitation at the scene treatment? and hirs recovered r.t,hile at the hospital. She has no pertinent personal medical history. The patient t:rkes no medications. (A) Digoxin On physical examination, vital signs are normal. The (B) Empagliflozin remainder of the examination is unremarkable. (C) Furosemide Laboratory studies are within normal limits. (D) Isosorbidedinitrate hydralazine Eclrocardiogram shows normal left ventricular func- tion and right ventricular dilation and dysfunction. Results fiom cardiac catheterization are normal. Metoprolol is initiated. Item 11 A 70 year old man is evaluated for recently diagnosed par Which of the following is the most appropriate additional oxysmal atrial flbrillation that is mildly symptomatic. Med management before discharge? ical history is significant for hypertension and previous stroke. Medications are rivaroxaban and metoprolol. He (A) Amiodarone has experienced no episodes ofbleeding on anticoagulation (B) Genetic testing therapy.

cardiac arrcst that occurrecl cluring a collegiate cross country Which of the following is the most appropriate additional race. She received cardiopulmonary resuscitation at the scene treatment? and hirs recovered r.t,hile at the hospital. She has no pertinent personal medical history. The patient t:rkes no medications. (A) Digoxin On physical examination, vital signs are normal. The (B) Empagliflozin remainder of the examination is unremarkable. (C) Furosemide Laboratory studies are within normal limits. (D) Isosorbidedinitrate hydralazine Eclrocardiogram shows normal left ventricular func- tion and right ventricular dilation and dysfunction. Results fiom cardiac catheterization are normal. Metoprolol is initiated. Item 11 A 70 year old man is evaluated for recently diagnosed par Which of the following is the most appropriate additional oxysmal atrial flbrillation that is mildly symptomatic. Med management before discharge? ical history is significant for hypertension and previous stroke. Medications are rivaroxaban and metoprolol. He (A) Amiodarone has experienced no episodes ofbleeding on anticoagulation (B) Genetic testing therapy. 127

I : 1 l Self-Assessment Test l I ttt I .D (C) Peripartum cardiomyopathy J On physical examination, blood pressure is 128/74 mm D vt Hg and pulse rate is 72lmin and regular. The remainder of (D) Spontaneous coronary artery dissectior.r I ) UI .D the examination is unremarkable. 1 gr Ut An echocardiogram reveals an enlarged Ieft atrium and \ .D normal left ventricle. Forty-eight-hour ambulatory ECG monitoring shows atrial flbrillation prevalence of 10% with a controlled ventricular rate less than 90i min and no other Item 14 A 68-year-old man is evaluated in the hospital for a 1 month tr J

UI .D the examination is unremarkable. 1 gr Ut An echocardiogram reveals an enlarged Ieft atrium and \ .D normal left ventricle. Forty-eight-hour ambulatory ECG monitoring shows atrial flbrillation prevalence of 10% with a controlled ventricular rate less than 90i min and no other Item 14 A 68-year-old man is evaluated in the hospital for a 1 month tr J I a history of nonproductive cough, dyspnea. and constant .D lrt abnormalities. : chest pressure. He is a never-smoker. i On physical examination. blood pressure is 106,62 mm Which of the following is the most appropriate treatment? Hg with 18 mm FIg pulsus paradoxus. and pulse rate is i

I a history of nonproductive cough, dyspnea. and constant .D lrt abnormalities. : chest pressure. He is a never-smoker. i On physical examination. blood pressure is 106,62 mm Which of the following is the most appropriate treatment? Hg with 18 mm FIg pulsus paradoxus. and pulse rate is i (A) Left atrial appendage occlusion l001min. Central venous pressure is elevated, and heart sounds are distant. (B) Pacemakerimplantation '! A fbcused echocardiogram short,s a 2 cm circumfer (C) Rhythm control ential pericardial eflusion with evidence of tamponade. I (D) Switch rivaroxaban to warfarin Pericardiocentesis yields 650 ml- of sanguinous fluid with 1 (E) No additional therapy marked improvement in symptoms. 1 A transthoracic echocardiogram (apical four chamber I vierv) after pericardiocentesis is shor,r'n (RA = right atrium, J ! Item 12 RV = right ventricle. LV = left ventricle, EFF = pericardial ! A S7-year-old man is evaluated for a 6-month history of effusion). A chest CT scan with contrast after pericardiocen stable chest pain. He experiences chest pressure that occurs tesis reveals a 4-mm right middle lobe nodule and a small I pericardial effusion with drain in place. A :l x 3 cm right ! after walking 1 mile and resolves promptly with rest. He has l I no symptoms at rest. His history includes aspirin allergy atrial mass is present, contiguous u'ith the lateral w'all of' I manifesting as hives and difficulty breathing after taking the right atrium. I 325 mg of aspirin as a teenager. He is a never smoker. He has hyperlipidemia. His only medication is atorvastatin. On physical examination, vital signs are normal. BMI l i is 30. the remainder of the examination is normal. Resting ECG is normal, and an exercise ECG is scheduled. i The patient receives counseling on lifestyle interven- tions to reduce his risk for disease progression. Antianginal I medications will be initiated. 'l I ! Which of the following is the most appropriate cardioprotective treatment? I

(A) Left atrial appendage occlusion l001min. Central venous pressure is elevated, and heart sounds are distant. (B) Pacemakerimplantation '! A fbcused echocardiogram short,s a 2 cm circumfer (C) Rhythm control ential pericardial eflusion with evidence of tamponade. I (D) Switch rivaroxaban to warfarin Pericardiocentesis yields 650 ml- of sanguinous fluid with 1 (E) No additional therapy marked improvement in symptoms. 1 A transthoracic echocardiogram (apical four chamber I vierv) after pericardiocentesis is shor,r'n (RA = right atrium, J ! Item 12 RV = right ventricle. LV = left ventricle, EFF = pericardial ! A S7-year-old man is evaluated for a 6-month history of effusion). A chest CT scan with contrast after pericardiocen stable chest pain. He experiences chest pressure that occurs tesis reveals a 4-mm right middle lobe nodule and a small I pericardial effusion with drain in place. A :l x 3 cm right ! after walking 1 mile and resolves promptly with rest. He has l I no symptoms at rest. His history includes aspirin allergy atrial mass is present, contiguous u'ith the lateral w'all of' I manifesting as hives and difficulty breathing after taking the right atrium. I 325 mg of aspirin as a teenager. He is a never smoker. He has hyperlipidemia. His only medication is atorvastatin. On physical examination, vital signs are normal. BMI l i is 30. the remainder of the examination is normal. Resting ECG is normal, and an exercise ECG is scheduled. i The patient receives counseling on lifestyle interven- tions to reduce his risk for disease progression. Antianginal I medications will be initiated. 'l I ! Which of the following is the most appropriate cardioprotective treatment? I (A) Clopidogrel (B) Low-dose aspirin (C) Prasugrel (D) Ticagrelor Which of the following is the most likely diagrosis?

(A) Left atrial appendage occlusion l001min. Central venous pressure is elevated, and heart sounds are distant. (B) Pacemakerimplantation '! A fbcused echocardiogram short,s a 2 cm circumfer (C) Rhythm control ential pericardial eflusion with evidence of tamponade. I (D) Switch rivaroxaban to warfarin Pericardiocentesis yields 650 ml- of sanguinous fluid with 1 (E) No additional therapy marked improvement in symptoms. 1 A transthoracic echocardiogram (apical four chamber I vierv) after pericardiocentesis is shor,r'n (RA = right atrium, J ! Item 12 RV = right ventricle. LV = left ventricle, EFF = pericardial ! A S7-year-old man is evaluated for a 6-month history of effusion). A chest CT scan with contrast after pericardiocen stable chest pain. He experiences chest pressure that occurs tesis reveals a 4-mm right middle lobe nodule and a small I pericardial effusion with drain in place. A :l x 3 cm right ! after walking 1 mile and resolves promptly with rest. He has l I no symptoms at rest. His history includes aspirin allergy atrial mass is present, contiguous u'ith the lateral w'all of' I manifesting as hives and difficulty breathing after taking the right atrium. I 325 mg of aspirin as a teenager. He is a never smoker. He has hyperlipidemia. His only medication is atorvastatin. On physical examination, vital signs are normal. BMI l i is 30. the remainder of the examination is normal. Resting ECG is normal, and an exercise ECG is scheduled. i The patient receives counseling on lifestyle interven- tions to reduce his risk for disease progression. Antianginal I medications will be initiated. 'l I ! Which of the following is the most appropriate cardioprotective treatment? I (A) Clopidogrel (B) Low-dose aspirin (C) Prasugrel (D) Ticagrelor Which of the following is the most likely diagrosis? tr Item 13 A 22 year old woman is evaluated in the emergency depart (A) Atrial myxoma (B) Bronchogenic carcinoma with cardiac metastasis ment tbr orthopnea and paroxysntal nocturnal dyspnea. (C) Cardiacangiosarcoma She is B days postpartum. Delivery was uncomplicated, and (D) Papillaryfibroelastoma she was discharged home the following day. She has no other medical problems and takes no medications. On physical exanlination, blood pressure is 108/82 nrm Item 15 tIg in both arms, pulse rate is 112/min and regular, and respi ration rate is 261min. 'lhe central venous pressure is elevated, A 72'year-old man is hospitalized with decompensated tx and an S., and bilateral pulmonary crackles are present. heart failure. Initial overnight treatment consisted of intra A chest radiograph shows pulmonary edema. An ECC venous furosemide equal to his total oral outpatient dose (40 mg). Overnight urine output was 250 mt-, with nochange reveals sinus tachycarclia without ischemic changes. Trans thoracic echocardiogram shows left ventricular dilatation in his symptoms. Medical history is significant for hyperlip- with global hypokinesis; ejection lraction is 38'7,. Right idemia and hypertension. Outpatient medications are lisin heart size and flunction are normal. opril, nretoprolol succinate, furosemide. and aton'astatin. On physical examination, blood pressure is 122 82 mm Which of the following is the most likely diagnosis? Hg, pulse rate is B8/min. respiration rate is 26, min. and oxy gen saturation is 95'2, with the patient breathing 2 L/min (A) Acute pulmonary embolism ot'oxygen by nasal cannula. I{e is alert, and his skin is (B) Asccnding aortic dissection warm and dry. Central venous pressure is elevated. Cardiac

tr Item 13 A 22 year old woman is evaluated in the emergency depart (A) Atrial myxoma (B) Bronchogenic carcinoma with cardiac metastasis ment tbr orthopnea and paroxysntal nocturnal dyspnea. (C) Cardiacangiosarcoma She is B days postpartum. Delivery was uncomplicated, and (D) Papillaryfibroelastoma she was discharged home the following day. She has no other medical problems and takes no medications. On physical exanlination, blood pressure is 108/82 nrm Item 15 tIg in both arms, pulse rate is 112/min and regular, and respi ration rate is 261min. 'lhe central venous pressure is elevated, A 72'year-old man is hospitalized with decompensated tx and an S., and bilateral pulmonary crackles are present. heart failure. Initial overnight treatment consisted of intra A chest radiograph shows pulmonary edema. An ECC venous furosemide equal to his total oral outpatient dose (40 mg). Overnight urine output was 250 mt-, with nochange reveals sinus tachycarclia without ischemic changes. Trans thoracic echocardiogram shows left ventricular dilatation in his symptoms. Medical history is significant for hyperlip- with global hypokinesis; ejection lraction is 38'7,. Right idemia and hypertension. Outpatient medications are lisin heart size and flunction are normal. opril, nretoprolol succinate, furosemide. and aton'astatin. On physical examination, blood pressure is 122 82 mm Which of the following is the most likely diagnosis? Hg, pulse rate is B8/min. respiration rate is 26, min. and oxy gen saturation is 95'2, with the patient breathing 2 L/min (A) Acute pulmonary embolism ot'oxygen by nasal cannula. I{e is alert, and his skin is (B) Asccnding aortic dissection warm and dry. Central venous pressure is elevated. Cardiac 128

Self-Assessment Test UI {, tr CONT examination does not revcal an Sr. There is pitting edema to his knees. Serunr electrolytes are normal, creatinine levcl is (C) Metoprolol (D) Reassurance F o tr 1.5 mg/dl. (132.6 [mol/1,), and B type natriuretic peptide vt

UI {, tr CONT examination does not revcal an Sr. There is pitting edema to his knees. Serunr electrolytes are normal, creatinine levcl is (C) Metoprolol (D) Reassurance F o tr 1.5 mg/dl. (132.6 [mol/1,), and B type natriuretic peptide vt tr ta level is elevated. Item 18 o UT rrt A 7S-year old man is evaluated for a 3-week history of Which of the following is the most appropriate treatment? shortness of'breath and intermittent f'evers. l{e underwent (l, transcatheter aortic valve implantation tbr aortic stenosis vt (A) Add intravenous milrinone 3 years ago. He was admitted to the hospital 1 month agtr (B) Add intravenous nitroglycerin with diverticulitis and was treated with antibiotic therapy: (C) Discontinuemetoprolol he developed intermittent fevers 1 week later. His only med (D) Increaseintravenousfurosemide ication is low-dosc aspirin. On physical examination, temperaturc is 37.6 'C (99.7'F), blood pressureisl4SlT2 mm tJg, and pulse rate is

tr ta level is elevated. Item 18 o UT rrt A 7S-year old man is evaluated for a 3-week history of Which of the following is the most appropriate treatment? shortness of'breath and intermittent f'evers. l{e underwent (l, transcatheter aortic valve implantation tbr aortic stenosis vt (A) Add intravenous milrinone 3 years ago. He was admitted to the hospital 1 month agtr (B) Add intravenous nitroglycerin with diverticulitis and was treated with antibiotic therapy: (C) Discontinuemetoprolol he developed intermittent fevers 1 week later. His only med (D) Increaseintravenousfurosemide ication is low-dosc aspirin. On physical examination, temperaturc is 37.6 'C (99.7'F), blood pressureisl4SlT2 mm tJg, and pulse rate is tx AItem 16 60 year old woman is evalulted fbr severe abdominal 90/min. Cardiac examination reveals a normal S, and S, and no murmurs. There is no evidence olheart failure. pain. She was admitted to the hospital 2 days ago with a An ECC shows no notable findings. A transthoracic type B aortic dissection and treated medically. ller admis- echocardiogram shows a left ventricular ejection fraction sion CT angiogram revealcd an aortic dissection beginning of 55'1, with normal right ventricular function. A biopros just distal to the left subclavian artery and extending to the thetic aortic valve is evident, with fully mobile and nornral- distal aorta just below the in{erior mesenteric artery. Her appearing leaflets. synlptoms responded to morphine, esmcllol, and nitroprus- Three sets ofblood cultures are negative. side. Yesterclay, esmolol was replaced with metoprolol. She is taking no other medications. Which of the following is the most appropriate diagnostic On physical examination today, temperature is 37.2"C test? (99 'F), blood pressure is 120/80 mm Hg, pulse rate is 64lmin, and respiration rate is 20/min. Oxygen saturation is 9B'X, (A) Cardiac CT with the patient breathing ambicnt air. The patient is rest (B) Cardiac magnetic resonance imaging less. Despite significant abdominal pair.r. palpation reveais (C)'1'ransesophageal echocardiography mild to moderate tenderness and no guarding. The skin is (D) No further testing cool and mottled fiom the knees to the f'eet.

tx AItem 16 60 year old woman is evalulted fbr severe abdominal 90/min. Cardiac examination reveals a normal S, and S, and no murmurs. There is no evidence olheart failure. pain. She was admitted to the hospital 2 days ago with a An ECC shows no notable findings. A transthoracic type B aortic dissection and treated medically. ller admis- echocardiogram shows a left ventricular ejection fraction sion CT angiogram revealcd an aortic dissection beginning of 55'1, with normal right ventricular function. A biopros just distal to the left subclavian artery and extending to the thetic aortic valve is evident, with fully mobile and nornral- distal aorta just below the in{erior mesenteric artery. Her appearing leaflets. synlptoms responded to morphine, esmcllol, and nitroprus- Three sets ofblood cultures are negative. side. Yesterclay, esmolol was replaced with metoprolol. She is taking no other medications. Which of the following is the most appropriate diagnostic On physical examination today, temperature is 37.2"C test? (99 'F), blood pressure is 120/80 mm Hg, pulse rate is 64lmin, and respiration rate is 20/min. Oxygen saturation is 9B'X, (A) Cardiac CT with the patient breathing ambicnt air. The patient is rest (B) Cardiac magnetic resonance imaging less. Despite significant abdominal pair.r. palpation reveais (C)'1'ransesophageal echocardiography mild to moderate tenderness and no guarding. The skin is (D) No further testing cool and mottled fiom the knees to the f'eet. Which of the following is the most appropriate next step in Item 19 management? A 42-year-old woman is seen to establish care. She is asymp- (A) Add intravenous enalaprilat tomatic. Medical history is signiflcant only for hypertension, (B) [ncreasenitroprussideinfusion for which she takes losartan; she has no history of diabetes mellitus or smoking. She does not take aspirin. Family his (C) Repair the descending aorta tory is noncontributory. (D) Switch esmolol to metoprolol On physical examination, blood pressure is 118/74 mm Hg. The remainder of the examination is unremarkable.

Which of the following is the most appropriate next step in Item 19 management? A 42-year-old woman is seen to establish care. She is asymp- (A) Add intravenous enalaprilat tomatic. Medical history is signiflcant only for hypertension, (B) [ncreasenitroprussideinfusion for which she takes losartan; she has no history of diabetes mellitus or smoking. She does not take aspirin. Family his (C) Repair the descending aorta tory is noncontributory. (D) Switch esmolol to metoprolol On physical examination, blood pressure is 118/74 mm Hg. The remainder of the examination is unremarkable. Item 17 Laboratory studies (nonfasting) : A 72 year-old man is evaluated during a routine physical Total cholesterol 24lmgldL (6.24 mmol/L) examination. He feels well and reports no exertional lim- HDL cholesterol 99 mgldL (2.s6 mmol/L) itations. He has no pertinent personal or family history. He LDL cholesterol 116 mg/dl (3.00 mmol/L)

Item 17 Laboratory studies (nonfasting) : A 72 year-old man is evaluated during a routine physical Total cholesterol 24lmgldL (6.24 mmol/L) examination. He feels well and reports no exertional lim- HDL cholesterol 99 mgldL (2.s6 mmol/L) itations. He has no pertinent personal or family history. He LDL cholesterol 116 mg/dl (3.00 mmol/L) takes no medications. Triglycerides 128 mg/dl (1.45 mmoUl) On physical examination, pulse rate is 72lmin with occasional irregularity; other vital signs are normal. On Which of the following is the most appropriate next step in cardiac examination, heart sounds are regular, with occa management? sional premature beats associated with cannon c waves (A) Begin high intensity statin therapy on neck examination. The remainder of the examination is (B) Begin high-intensity statin therapy and ezetimibe unremarkable. (C) Calculate 10 year risk for atherosclerotic cardiovascular Laboratory studies, including complete blood count disease and thyroid stimulating hormone level, are normal. ECG shows one premature ventricular contraction and (D) Repeat lipid proflle while fasting is otherwise normal.

takes no medications. Triglycerides 128 mg/dl (1.45 mmoUl) On physical examination, pulse rate is 72lmin with occasional irregularity; other vital signs are normal. On Which of the following is the most appropriate next step in cardiac examination, heart sounds are regular, with occa management? sional premature beats associated with cannon c waves (A) Begin high intensity statin therapy on neck examination. The remainder of the examination is (B) Begin high-intensity statin therapy and ezetimibe unremarkable. (C) Calculate 10 year risk for atherosclerotic cardiovascular Laboratory studies, including complete blood count disease and thyroid stimulating hormone level, are normal. ECG shows one premature ventricular contraction and (D) Repeat lipid proflle while fasting is otherwise normal. Which of the following is the most appropriate management? Item 20 A 59 year old woman is evaluatcd in the emergency depart- tr ment fbr two episodes of'crushing chest pair.r occurring (A) Cardiac magnetic resonance imaging at rest during the past 24 hours. The last episode occurred (B) Exercise ECG 2 hours agoi she is currently pain free. She has no history 129

I I 1 i Self-Assessment Test v!) o + D i ,a I UT I o U) \,t l,t .D cvt .\1- \: u .1 Il l*2. ?: il \ YI 1 f, ITEM 2()

u .1 Il l*2. ?: il \ YI 1 f, ITEM 2() Fn I \,)l ,l,.il\ .rli( r\ rlirt'.i:r'()r lt('.ll'l l.rilurc srrnptrlt-tls. IIis The patient is Jnrolled in a supervised exercise pro Ll ,, ,, i. rr.,r rirlt',,r'ir l,,r'irr|rllr'rr'i,,lt ll'(,.llr,d rrith ittttkrtli gram. CONT. ltritr: sltr:1:rl.t's n().)ilr!'r'rttt'rlir.tliotts. .\spirirt. itltr.ttcttotts unI rt! ir )i l.t ( t1 tt,p-rlil. 111i1 p11,1oltroloI rtre in iti;rtccl. 1 I I Which of the following is the most appropriate treatment 1 ( )n i)il\ si(.ll r'\.lrllill,iti()ll. \ it.ll \igll\ al-e llorlllill.'lh(] to reduce this patient's cardiovascular risk? r.rr 1r.r i il (l('r ( )1 t i rr' c\.l lI i ll.t i iot.t i : Llll r('lllitrliill)le. (A) Cilostazol Ilr(' iniljJI lri{lr sr'n:itir itr clrtli;-tc lro})ollill ler-el is rtont.r.r I i::()()1 h I rL:r( rn I i le' Lrpltt'r re'f trttrce lintit ). (B) Ezetimibe 1..( (, is sltln tr. (C) Peripheral artery bypass surgery Ilrt't.tlritlrtti'ri I l\ll st,rt' is l. (D) Rivaroxaban (E) Ticagrelor \l lrich of tlre follorving is the most appropriate additional nlxnageme rrt'l (.\) (.lopitlogrt'i llem 22 {ll) \itroqirrr'r'irt irtlttsiott A 56 year-old man is evaluated during a follow up visit for ischemic cardiomyopathy (ejection fraction. 20'7,). He ((.) 'l iloljbrrn jrlitsiott has had lwo heart failure hospitalizations in the past year. (l r) I rqent L'()r-()nil1'\ rrrtrliogr.tltltr He can no longer perform household chores. He also has hypertension and chronic kidney disease. with a baseline serum creatinine level of 1.5 mg/dl (132.6 Umol/L). He is Item 21 receiving maximally tolerated heart failure therapy consist A 68 year old man is evaluated for a 6-month history of ing of losartan, carvedilol, furosemide, and spironolactone. intermittent claudication. His symptoms have been slowly Physical examination flndings, including vital signs, progressive but are not life limiting. Medical history is are normal. signiflcant for hypertension, hyperlipidemia, and carotid Serum creatinine level is 1.9 mg/dl (168 pmol/L), artery stenosis treated with left carotid endarterectomy. He serum potassium level is 5.3 mEq/L (5.3 mmolil). and is a former smoker but quit 10 years ago. Medications are serum sodium level is 129 mEq/L (129 mmol/L). low-dose aspirin, high-intensity rosuvastatin, and losartan. The patient wishes to pursue care that will restore On physical examination, vital signs are normal. The dor- functionality. salis pedis and posterior tibialis pulses are diminished bilat erally. Bilateral femoral bruits and carotid bruits are noted. Which ofthe following is the most appropriate long-term Ankle brachial index measurements conflrm the diagnosis of treatment? bilateral lower extremity peripheral artery disease. Laboratory studies reveal a serum LDL cholesterol level (A) Digoxin of 56 mg/dl (r.+s mmol/L). (B) Hearttransplantation

Fn I \,)l ,l,.il\ .rli( r\ rlirt'.i:r'()r lt('.ll'l l.rilurc srrnptrlt-tls. IIis The patient is Jnrolled in a supervised exercise pro Ll ,, ,, i. rr.,r rirlt',,r'ir l,,r'irr|rllr'rr'i,,lt ll'(,.llr,d rrith ittttkrtli gram. CONT. ltritr: sltr:1:rl.t's n().)ilr!'r'rttt'rlir.tliotts. .\spirirt. itltr.ttcttotts unI rt! ir )i l.t ( t1 tt,p-rlil. 111i1 p11,1oltroloI rtre in iti;rtccl. 1 I I Which of the following is the most appropriate treatment 1 ( )n i)il\ si(.ll r'\.lrllill,iti()ll. \ it.ll \igll\ al-e llorlllill.'lh(] to reduce this patient's cardiovascular risk? r.rr 1r.r i il (l('r ( )1 t i rr' c\.l lI i ll.t i iot.t i : Llll r('lllitrliill)le. (A) Cilostazol Ilr(' iniljJI lri{lr sr'n:itir itr clrtli;-tc lro})ollill ler-el is rtont.r.r I i::()()1 h I rL:r( rn I i le' Lrpltt'r re'f trttrce lintit ). (B) Ezetimibe 1..( (, is sltln tr. (C) Peripheral artery bypass surgery Ilrt't.tlritlrtti'ri I l\ll st,rt' is l. (D) Rivaroxaban (E) Ticagrelor \l lrich of tlre follorving is the most appropriate additional nlxnageme rrt'l (.\) (.lopitlogrt'i llem 22 {ll) \itroqirrr'r'irt irtlttsiott A 56 year-old man is evaluated during a follow up visit for ischemic cardiomyopathy (ejection fraction. 20'7,). He ((.) 'l iloljbrrn jrlitsiott has had lwo heart failure hospitalizations in the past year. (l r) I rqent L'()r-()nil1'\ rrrtrliogr.tltltr He can no longer perform household chores. He also has hypertension and chronic kidney disease. with a baseline serum creatinine level of 1.5 mg/dl (132.6 Umol/L). He is Item 21 receiving maximally tolerated heart failure therapy consist A 68 year old man is evaluated for a 6-month history of ing of losartan, carvedilol, furosemide, and spironolactone. intermittent claudication. His symptoms have been slowly Physical examination flndings, including vital signs, progressive but are not life limiting. Medical history is are normal. signiflcant for hypertension, hyperlipidemia, and carotid Serum creatinine level is 1.9 mg/dl (168 pmol/L), artery stenosis treated with left carotid endarterectomy. He serum potassium level is 5.3 mEq/L (5.3 mmolil). and is a former smoker but quit 10 years ago. Medications are serum sodium level is 129 mEq/L (129 mmol/L). low-dose aspirin, high-intensity rosuvastatin, and losartan. The patient wishes to pursue care that will restore On physical examination, vital signs are normal. The dor- functionality. salis pedis and posterior tibialis pulses are diminished bilat erally. Bilateral femoral bruits and carotid bruits are noted. Which ofthe following is the most appropriate long-term Ankle brachial index measurements conflrm the diagnosis of treatment? bilateral lower extremity peripheral artery disease. Laboratory studies reveal a serum LDL cholesterol level (A) Digoxin of 56 mg/dl (r.+s mmol/L). (B) Hearttransplantation 130

Self-Assessment Test Ut 6' (C) Left ventricular assist device placement (lirrcliirc cathete rizrtion ret ells normal coronan' arter F (D) Tolvaptan ie-s. Aclnri nistratiolr of i ntriicoroltxr)' n i t roglyc'eri rl shott's nrr change in corclnary xrtcry diantctcr. o (-irrdiirc nragne tic rcsoltilncc inragir-rg finclings short, E UI vt Item 23 clillusc pcrtusion lbnornralities. o UI vt A 48 year old man is evaluated for a 6 month history of dyspnea and near syncope with exertion. He has no other Which of the following is the most likely cause of this +(, medical problems and takes no medication. patient's chest pain? tt On physical examination, vital signs are normal. A grade (A) Coronary' \'ilsosl)rlsn1 3/6 systolic ejection quality murmur is heard along the left (B) N{icroi,asculirr il!stirnction sternal border. The carotid impulse is brisk. The murmur decreases significantly in intensity with the patient squatting. (C) l)eripartum crrclionrl'opathy There is no radiation of the murmur to the carotid arteries. No ([)) Spontaneolls coronary artery clissection ejection sound or systolic click is heard. There is no variation with respiration, and no diastolic murmur is present. Item 25 Which of the following is the most likely diagnosis? A 42 year old wonran is evaluated in the emergency (A) Bicuspid aorlic slenosis department for abrupt-onset palpitations. For the past year, she has been having similar episodes with (B) Hypertrophic cardiomyopath)' increasing frequency. She has been able to stop these (C) Restrictive membranous ventricular septal defect previous episodes by coughing. She reports no syncopal (D) Ruptured sinus of Valsalva aneurysm episodes. On physical examination, blood pressure is 95/68 mm Hg. pulse rate is 200/nrin, and respiration rate is l6lmin. AII

Ut 6' (C) Left ventricular assist device placement (lirrcliirc cathete rizrtion ret ells normal coronan' arter F (D) Tolvaptan ie-s. Aclnri nistratiolr of i ntriicoroltxr)' n i t roglyc'eri rl shott's nrr change in corclnary xrtcry diantctcr. o (-irrdiirc nragne tic rcsoltilncc inragir-rg finclings short, E UI vt Item 23 clillusc pcrtusion lbnornralities. o UI vt A 48 year old man is evaluated for a 6 month history of dyspnea and near syncope with exertion. He has no other Which of the following is the most likely cause of this +(, medical problems and takes no medication. patient's chest pain? tt On physical examination, vital signs are normal. A grade (A) Coronary' \'ilsosl)rlsn1 3/6 systolic ejection quality murmur is heard along the left (B) N{icroi,asculirr il!stirnction sternal border. The carotid impulse is brisk. The murmur decreases significantly in intensity with the patient squatting. (C) l)eripartum crrclionrl'opathy There is no radiation of the murmur to the carotid arteries. No ([)) Spontaneolls coronary artery clissection ejection sound or systolic click is heard. There is no variation with respiration, and no diastolic murmur is present. Item 25 Which of the following is the most likely diagnosis? A 42 year old wonran is evaluated in the emergency (A) Bicuspid aorlic slenosis department for abrupt-onset palpitations. For the past year, she has been having similar episodes with (B) Hypertrophic cardiomyopath)' increasing frequency. She has been able to stop these (C) Restrictive membranous ventricular septal defect previous episodes by coughing. She reports no syncopal (D) Ruptured sinus of Valsalva aneurysm episodes. On physical examination, blood pressure is 95/68 mm Hg. pulse rate is 200/nrin, and respiration rate is l6lmin. AII tr Item 24 A :l:l ycxr olcl r,r,onrrur is hospitalized firr acute crusl.ring other physical exanrination findings are unremarkable. ECG is shown. A previous ECG showed sinus rhythm with ir heart rate ot'72lmin without any abnormalities. st-tbsternal chesf pain, which occurreci n,hile jogging irnd resolvecl r.r.ith rest. The pain wirs associated r,r,ith nausea lrnd cliaphoresis. Shc hirs hacl several previous cpisodes of'cl.rest Which of the following is the most likely rhythm pirin u,ith activitv. rrlthough thc pain r.r'as lcss se.',ere. She is diagnosis? ll nronths postpilrtum front an uncomplicaterl spontancous (A) Atrial fibrillation vaginrrl delirrery. (B) Atrial tachycardia ln the enrergency departnrcnt. bkrod prcssure \\/rs 1O.1 76 nrm Hg. an<l pr-rlserltc urls lll nrin. lhe rentlintlcr (C) Atrioventricularnodalreentranttachycardia of the erarniniition u,as unrernirrklble . (D) Ventriculartachycardia

tr Item 24 A :l:l ycxr olcl r,r,onrrur is hospitalized firr acute crusl.ring other physical exanrination findings are unremarkable. ECG is shown. A previous ECG showed sinus rhythm with ir heart rate ot'72lmin without any abnormalities. st-tbsternal chesf pain, which occurreci n,hile jogging irnd resolvecl r.r.ith rest. The pain wirs associated r,r,ith nausea lrnd cliaphoresis. Shc hirs hacl several previous cpisodes of'cl.rest Which of the following is the most likely rhythm pirin u,ith activitv. rrlthough thc pain r.r'as lcss se.',ere. She is diagnosis? ll nronths postpilrtum front an uncomplicaterl spontancous (A) Atrial fibrillation vaginrrl delirrery. (B) Atrial tachycardia ln the enrergency departnrcnt. bkrod prcssure \\/rs 1O.1 76 nrm Hg. an<l pr-rlserltc urls lll nrin. lhe rentlintlcr (C) Atrioventricularnodalreentranttachycardia of the erarniniition u,as unrernirrklble . (D) Ventriculartachycardia I ,l lllrtrll iI r rliltrliti; ,l .r. ll ... tl r. ,' --\r, .1j1/ \*rlf L-[/L ,l Y' t, t' ,i ,t I 7 i! I ITEM 25 131

Self-Assessment Test vr .D The ankle-brachial index is 0.92 on the right and 0.94 + Item 26 on the left. UI a A 65-year-old woman is evaluated in follow-up for a recent .D diagnosis of nonischemic cardiomyopathy. Her symptoms UI Which of the following is the most appropriate test to UI included dyspnea with minimal exertion and orthopnea. perform next? .D The initial evaluation also revealed echocardiographic flnd- ings compatible with severe secondary mitral regurgitation (A) Exercise ankle brachial index testing { .D (mitral annular dilation without any mitral leaflet abnor- (B) Invasiveangiography UI malities) and a left ventricular ejection fraction of 4O%. (C) Magneticresonanceangiography Image quality was excellent. Lisinopril, carvedilol, spirono- lactone, and furosemide have been titrated to achieve max- (D) Segmental lower extremity blood pressure testing imal therapeutic effectiveness. Her symptoms are now New York Heart Association functional class I. On physical examination, blood pressure is 95/62 mm Item 29 Hg and pulse rate is 7Olmin; other vital signs are normal. A A 57 year-old woman is evaluated in the emergency holosystolic murmur is loudest at the apex. Central venous department for an acute anterior ST-elevation myocardial pressure is slightly elevated. Lungs are clear. infarction. Aspirin, ticagrelor, unfractionated heparin. and intra Which of the following is the most appropriate additional venous nitroglycerin are initiated. Emergent coronary management? angiography reveals an acutely occluded proximal left anterior descending (LAD) coronary artery and 70'U, stenosis (A) Cardiac magnetic resonance imaging of the mid right coronary artery. The LAD lesion is treated (B) Cardiac resynchronizationtherapy with drug eluting stent placement, resulting in resolution (C) Surgical mitral valve repair of chest pain and improvement in the ST-segment elevation (D) No additional therapy seen on ECG. Following successful percutaneous coronary interven tion, blood pressure is 138/82 mm Hg, pulse rate is 7Srmin. Item 27 respiration rate is l8/min, and oxygen saturation is 94'7, A 42 year old man is evaluated during a follow-up visit for with the patient breathing ambient air. The remainder of the a patent ductus arteriosus (PDA) identified early in life. He examination is unremarkable. had regular follow-up visits through adolescence but has not had a medical evaluation recently. He is asymptomatic. Which of the following is the most appropriate additional On physical examination, blood pressure is 120/70 mm management? Hg. Apical impulse is displaced laterally. A continuous mur- (A) Glycoprotein IIb/llla inhibitor infusion mur that envelops the S, is heard beneath the left clavicle. (B) Predischarge exercise ECG The remainder of the cardiac examination is unremarkable. Echocardiogram demonstrates a PDA with left-to-right (C) nignt coronary artery revascularization shunt. The left atrium and left ventricle are moderately (D) Supplementaloxygen enlarged, and the left ventricular ejection fraction is 63%. The right heart chambers are normal in size. The estimated right ventricular systolic pressure is 30 mm Hg. Item 30 A 4l-year-old man is evaluated for a 2 week history of Which of the following is the most appropriate daily palpitations that last minutes at a time and resolve management? spontaneously. The palpitations are not associated with any specific activity. He is otherwise healthy and takes no (A) Cardiac magnetic resonance imaging medications. (B) Indomethacin Physical examination flndings, including vital signs, (C) PDA device closure are normal. (D) Serial echocardiographicmonitoring Which of the following is the most appropriate initial test?

vr .D The ankle-brachial index is 0.92 on the right and 0.94 + Item 26 on the left. UI a A 65-year-old woman is evaluated in follow-up for a recent .D diagnosis of nonischemic cardiomyopathy. Her symptoms UI Which of the following is the most appropriate test to UI included dyspnea with minimal exertion and orthopnea. perform next? .D The initial evaluation also revealed echocardiographic flnd- ings compatible with severe secondary mitral regurgitation (A) Exercise ankle brachial index testing { .D (mitral annular dilation without any mitral leaflet abnor- (B) Invasiveangiography UI malities) and a left ventricular ejection fraction of 4O%. (C) Magneticresonanceangiography Image quality was excellent. Lisinopril, carvedilol, spirono- lactone, and furosemide have been titrated to achieve max- (D) Segmental lower extremity blood pressure testing imal therapeutic effectiveness. Her symptoms are now New York Heart Association functional class I. On physical examination, blood pressure is 95/62 mm Item 29 Hg and pulse rate is 7Olmin; other vital signs are normal. A A 57 year-old woman is evaluated in the emergency holosystolic murmur is loudest at the apex. Central venous department for an acute anterior ST-elevation myocardial pressure is slightly elevated. Lungs are clear. infarction. Aspirin, ticagrelor, unfractionated heparin. and intra Which of the following is the most appropriate additional venous nitroglycerin are initiated. Emergent coronary management? angiography reveals an acutely occluded proximal left anterior descending (LAD) coronary artery and 70'U, stenosis (A) Cardiac magnetic resonance imaging of the mid right coronary artery. The LAD lesion is treated (B) Cardiac resynchronizationtherapy with drug eluting stent placement, resulting in resolution (C) Surgical mitral valve repair of chest pain and improvement in the ST-segment elevation (D) No additional therapy seen on ECG. Following successful percutaneous coronary interven tion, blood pressure is 138/82 mm Hg, pulse rate is 7Srmin. Item 27 respiration rate is l8/min, and oxygen saturation is 94'7, A 42 year old man is evaluated during a follow-up visit for with the patient breathing ambient air. The remainder of the a patent ductus arteriosus (PDA) identified early in life. He examination is unremarkable. had regular follow-up visits through adolescence but has not had a medical evaluation recently. He is asymptomatic. Which of the following is the most appropriate additional On physical examination, blood pressure is 120/70 mm management? Hg. Apical impulse is displaced laterally. A continuous mur- (A) Glycoprotein IIb/llla inhibitor infusion mur that envelops the S, is heard beneath the left clavicle. (B) Predischarge exercise ECG The remainder of the cardiac examination is unremarkable. Echocardiogram demonstrates a PDA with left-to-right (C) nignt coronary artery revascularization shunt. The left atrium and left ventricle are moderately (D) Supplementaloxygen enlarged, and the left ventricular ejection fraction is 63%. The right heart chambers are normal in size. The estimated right ventricular systolic pressure is 30 mm Hg. Item 30 A 4l-year-old man is evaluated for a 2 week history of Which of the following is the most appropriate daily palpitations that last minutes at a time and resolve management? spontaneously. The palpitations are not associated with any specific activity. He is otherwise healthy and takes no (A) Cardiac magnetic resonance imaging medications. (B) Indomethacin Physical examination flndings, including vital signs, (C) PDA device closure are normal. (D) Serial echocardiographicmonitoring Which of the following is the most appropriate initial test? Item 28 (A) Exercise ECG (B) 30-Day event monitor A 74 year-old man is evaluated for a 6-month history of progressive bilateral calf pain. The discomfort is worse with (C) rz Lead resting ECG walking and improves quickly with rest. Medical history is (D) 24-Hour ambulatory ECG monitor signiflcant for hypertension and hyperlipidemia. He has a S0-pack year history of smoking but quit 5 years ago. Med- ications are rosuvastatin, quinapril, and metoprolol. Item 31 On physical examination, vital signs are normal. A A 34-year-old woman is evaluated for exertional dyspnea right femoral bruit is noted. Bilateral femoral pulses and when walking up stairs or carrying groceries from the : pedal pulses are faint. Motor and sensory examinations are car. Six months ago, she was diagnosed with heart failure normal; reflexes are normal. 1 month after her last pregnancy. She has no traditional : l 132 I I

Self-Assessment Test rtl atherosclerotic risk factors. Medications are valsartan Item 33 o F sacubitril, carvedilol, furosemide, and spironolactone. The A 68-year-old man is evaluated I month after atherectomy o patient is Black. and stenting ofthe right superflcial femoral artery for severe E On physical examination, blood pressure is 138/76 mm UI claudication. Since the procedure, he can walk and perform ta Hg and pulse rate is 64lmin. The remainder of the examina- all of his customary activities without claudication. Medical o UI tion is unremarkable. history is signiflcant for hypertension, hyperlipidemia, and U! Laboratory studies are within normal limits. coronary artery disease. He exercises 150 minutes weekly Repeat echocardiogram shows an ejection fraction of and consumes a heart healthy diet. He quit smoking 15 years o rrt 25"/,,. ago. Medications are low dose aspirin, low-dose rivarox- aban, metoprolol, ramipril, and high intensity rosuvastatin. Which of the following is the most appropriate treatment? On physical examination, blood pressure is 124i70 mm (A) Digoxin Hg. The remainder of the physical examination is unre markable. (B) Isosorbide dinitrate-hydralazine Laboratory studies reveal a serum total cholesterol level (C) Liraglutide of 120 mg/dl (3.1 mmol/L), serum LDL cholesterol level of (D) Lisinopril 50 mg/dl (t.s mmol/L), and serum HDL cholesterol level of 4smgldL (t.zmmol/L).

rtl atherosclerotic risk factors. Medications are valsartan Item 33 o F sacubitril, carvedilol, furosemide, and spironolactone. The A 68-year-old man is evaluated I month after atherectomy o patient is Black. and stenting ofthe right superflcial femoral artery for severe E On physical examination, blood pressure is 138/76 mm UI claudication. Since the procedure, he can walk and perform ta Hg and pulse rate is 64lmin. The remainder of the examina- all of his customary activities without claudication. Medical o UI tion is unremarkable. history is signiflcant for hypertension, hyperlipidemia, and U! Laboratory studies are within normal limits. coronary artery disease. He exercises 150 minutes weekly Repeat echocardiogram shows an ejection fraction of and consumes a heart healthy diet. He quit smoking 15 years o rrt 25"/,,. ago. Medications are low dose aspirin, low-dose rivarox- aban, metoprolol, ramipril, and high intensity rosuvastatin. Which of the following is the most appropriate treatment? On physical examination, blood pressure is 124i70 mm (A) Digoxin Hg. The remainder of the physical examination is unre markable. (B) Isosorbide dinitrate-hydralazine Laboratory studies reveal a serum total cholesterol level (C) Liraglutide of 120 mg/dl (3.1 mmol/L), serum LDL cholesterol level of (D) Lisinopril 50 mg/dl (t.s mmol/L), and serum HDL cholesterol level of 4smgldL (t.zmmol/L). Item 32 Which of the following is the most appropriate additional A 56 year-old man is evaluated in the emergency depart- treatment? ment for acute shortness of breath and the sensation of a (A) Cilostazol racing heart. His only medical problem is hypertension treated with chlorthalidone. (B) Evolocumab On physical examination, blood pressure is 89/52 mm (C) Ticagrelor Hg and pulse rate is 150/min. Cardiac examination reveals a (D) No additional treatment regular tachycardia. Jugular venous distention and pulmo nary crackles are present. ECG is shown. The patient is successfully cardioverted. Item 34 A 47-year old man is evaluated for a heart murmur. He is Which of the following is the most appropriate additional asymptomatic and has no exercise limitations. treatment? On physical examination, vital signs, including blood pressure, are normal. There is a grade 1/6 decrescendo dia- (A) Amiodarone stolic murmur heard at the left sternal border. The remain- (B) Catheter ablation der of the examination is normal. (C) Flecainide Echocardiogram shows a left ventricular ejection frac- (D) Metoprolol tion of 557,, a bicuspid aortic valve with mild aortic regurgi (E) No additional treatment tation, and a normal left ventricular end systolic dimension'

Item 32 Which of the following is the most appropriate additional A 56 year-old man is evaluated in the emergency depart- treatment? ment for acute shortness of breath and the sensation of a (A) Cilostazol racing heart. His only medical problem is hypertension treated with chlorthalidone. (B) Evolocumab On physical examination, blood pressure is 89/52 mm (C) Ticagrelor Hg and pulse rate is 150/min. Cardiac examination reveals a (D) No additional treatment regular tachycardia. Jugular venous distention and pulmo nary crackles are present. ECG is shown. The patient is successfully cardioverted. Item 34 A 47-year old man is evaluated for a heart murmur. He is Which of the following is the most appropriate additional asymptomatic and has no exercise limitations. treatment? On physical examination, vital signs, including blood pressure, are normal. There is a grade 1/6 decrescendo dia- (A) Amiodarone stolic murmur heard at the left sternal border. The remain- (B) Catheter ablation der of the examination is normal. (C) Flecainide Echocardiogram shows a left ventricular ejection frac- (D) Metoprolol tion of 557,, a bicuspid aortic valve with mild aortic regurgi (E) No additional treatment tation, and a normal left ventricular end systolic dimension' 1 -l t I vt 16 rt I I I rrEir 32 133

Self-Assessment Test tr .D The ascending aorta is enlarged, with a dimension of 4.2 cm. Item 37 D UI UI Echocardiographic imaging quality of the aortic sinuses, A 6l y'ear old man is evalurted in the emergencl, depart EI sinotubularjunction, and ascending aorta is excellent. .D vl ment fbr palpitations that began this morning. He has a UI history of coronary artery disease treated rt'ith coronary' Which of the following is the most appropriate artery stenting lB months ago and left ventricular d_v''sfunc .D management? tion. Medications are aspirin, metoprolol. spironolactone. -t .D (A) Aortic valve replacement and repair of the ascending and lisinopril. ur On ph1'sical eramin:rtion, blood pressure is 100 65 nrm aorta (B) Cardiac magnetic resonance imaging IIg and pulse rate is 130'nrin: other vital signs are normal. Oxygen saturation is 98')1, lvith the patient breathing ambi (C) Echocardiographicsurveillance ent air. Intermittent cannon o waves are noted on neck (D) Initiation of losartan exanrination. Other than tachycardia. cardiac examinati<tn is normal. Breath sounds are clear. ECG rvith rhythm strips is shown (top of nert page). Item 35 A 48 year old man is evaluated for recurrent pericarditis. Which of the following is the most likely diagnosis? Six months ago, he had acute pericarditis treated with ibu (A) Monomorphicventriculartachl'cardia profen and colchicine. His symptoms resolved completely (B) Preexcitedtachycardia within 3 weeks of initiation of therapy. Evaluations for an infectious cause and connective tissue disease were nega (C) Suprirventricular tachy'cardia n'ith aberrano' tive. The patient's symptoms recurred after ibuprofen was (D) Torsades de pointes tapered over 1 month with continuation of colchicine. Ibu profen was re initiated at a high dose with resolution of symptoms and tapered over a 2 month period. His current Item 38 symptoms began 24 hours ago. Currently, his only medica A 47 year old man is evaluated for management of heart tion is colchicine. failure with reduced ejection fraction (ejection fraction, On physical examination, temperature is 38.0 'C 30'7,) diagnosed 3 years ago. He has New York Heart Asso (100.4 "F); other vital signs are normal. Pulsus paradoxus of ciation functional class III symptoms and has been stable 10 mm Hg is present. There is no jugular venous distention. for the past year. His medical history also includes ACE The lungs are clear to auscultation. A friction rub is heard at inhibitor-induced angioedema, spironolactone-induced the left sternal border and apex. gynecomastia, and atrial fibrillation. An implantable ECG shows normal sinus rhythm with widespread cardioverter defibrillator is in place. Medications are ST-segment elevation of 0.5 to 1.0 mm. Echocardiogram losartan, carvedilol, furosemide, and apixaban. shows a small circumferential pericardial effusion (diastolic On physical examination, blood pressure is 120/68 mm echo-free space, 3 mm) without evidence of tamponade. Hg and pulse rate is 7Srmin and irregular. Other than an irregularly irregular heart rhythm, the remainder of the Which of the following is the most appropriate treatment? examination is normal. (A) Anakinra Serum creatinine and electrolyte levels are normal. (B) Colchicine and intravenous immune globulin Which of the following is the most appropriate treatment? (C) Ibuprofen (D) Ibuprofen, colchicine, and prednisone (A) Add eplerenone (B) Add ivabradine (C) Switch carvedilol to metoprolol succinate Item 36 (D) Switch losartan to valsartan-sacubitril A 60 year old woman comes to the office for follow up evaluation 1 year after having a drug-eluting stent placed in the mid left anterior descending coronary artery to treat Item 39 non ST-elevation acute coronary syndrome. She has been A 45 year old man is seen for cardiovascular risk reduction. adherent to dual antiplatelet therapy for the past year with Hyperlipidemia was diagnosed 4 years ago and is treated out any bleeding events. The patient's only other medical withatorvastatin. t{ehasa35 pack yearhistoryofcigarette problem is diabetes mellitus. Medications are metformin. smoking and is a current smoker. Six months ago, predia liraglutide, atorvastatin, clopidogrel, and aspirin. betes was diagnosed. He occasionally has a depressed mood. He does not take aspirin on a regular basis. Which of the following is the most reasonable On physical examination, vital signs are normal. BMI management of the antiplatelet therapy? is 29. The remainder of the examination is unremarkable. (A) Stop aspirin (B) Stop aspirin and clopidogrel Which of the following is the most appmpriate management? (C) Stop clopidogrel and add low-dose rivaroxaban (A) Depression screening and treatment (D) Continue aspirin and clopidogrel (B) Low dose aspirin

tr .D The ascending aorta is enlarged, with a dimension of 4.2 cm. Item 37 D UI UI Echocardiographic imaging quality of the aortic sinuses, A 6l y'ear old man is evalurted in the emergencl, depart EI sinotubularjunction, and ascending aorta is excellent. .D vl ment fbr palpitations that began this morning. He has a UI history of coronary artery disease treated rt'ith coronary' Which of the following is the most appropriate artery stenting lB months ago and left ventricular d_v''sfunc .D management? tion. Medications are aspirin, metoprolol. spironolactone. -t .D (A) Aortic valve replacement and repair of the ascending and lisinopril. ur On ph1'sical eramin:rtion, blood pressure is 100 65 nrm aorta (B) Cardiac magnetic resonance imaging IIg and pulse rate is 130'nrin: other vital signs are normal. Oxygen saturation is 98')1, lvith the patient breathing ambi (C) Echocardiographicsurveillance ent air. Intermittent cannon o waves are noted on neck (D) Initiation of losartan exanrination. Other than tachycardia. cardiac examinati<tn is normal. Breath sounds are clear. ECG rvith rhythm strips is shown (top of nert page). Item 35 A 48 year old man is evaluated for recurrent pericarditis. Which of the following is the most likely diagnosis? Six months ago, he had acute pericarditis treated with ibu (A) Monomorphicventriculartachl'cardia profen and colchicine. His symptoms resolved completely (B) Preexcitedtachycardia within 3 weeks of initiation of therapy. Evaluations for an infectious cause and connective tissue disease were nega (C) Suprirventricular tachy'cardia n'ith aberrano' tive. The patient's symptoms recurred after ibuprofen was (D) Torsades de pointes tapered over 1 month with continuation of colchicine. Ibu profen was re initiated at a high dose with resolution of symptoms and tapered over a 2 month period. His current Item 38 symptoms began 24 hours ago. Currently, his only medica A 47 year old man is evaluated for management of heart tion is colchicine. failure with reduced ejection fraction (ejection fraction, On physical examination, temperature is 38.0 'C 30'7,) diagnosed 3 years ago. He has New York Heart Asso (100.4 "F); other vital signs are normal. Pulsus paradoxus of ciation functional class III symptoms and has been stable 10 mm Hg is present. There is no jugular venous distention. for the past year. His medical history also includes ACE The lungs are clear to auscultation. A friction rub is heard at inhibitor-induced angioedema, spironolactone-induced the left sternal border and apex. gynecomastia, and atrial fibrillation. An implantable ECG shows normal sinus rhythm with widespread cardioverter defibrillator is in place. Medications are ST-segment elevation of 0.5 to 1.0 mm. Echocardiogram losartan, carvedilol, furosemide, and apixaban. shows a small circumferential pericardial effusion (diastolic On physical examination, blood pressure is 120/68 mm echo-free space, 3 mm) without evidence of tamponade. Hg and pulse rate is 7Srmin and irregular. Other than an irregularly irregular heart rhythm, the remainder of the Which of the following is the most appropriate treatment? examination is normal. (A) Anakinra Serum creatinine and electrolyte levels are normal. (B) Colchicine and intravenous immune globulin Which of the following is the most appropriate treatment? (C) Ibuprofen (D) Ibuprofen, colchicine, and prednisone (A) Add eplerenone (B) Add ivabradine (C) Switch carvedilol to metoprolol succinate Item 36 (D) Switch losartan to valsartan-sacubitril A 60 year old woman comes to the office for follow up evaluation 1 year after having a drug-eluting stent placed in the mid left anterior descending coronary artery to treat Item 39 non ST-elevation acute coronary syndrome. She has been A 45 year old man is seen for cardiovascular risk reduction. adherent to dual antiplatelet therapy for the past year with Hyperlipidemia was diagnosed 4 years ago and is treated out any bleeding events. The patient's only other medical withatorvastatin. t{ehasa35 pack yearhistoryofcigarette problem is diabetes mellitus. Medications are metformin. smoking and is a current smoker. Six months ago, predia liraglutide, atorvastatin, clopidogrel, and aspirin. betes was diagnosed. He occasionally has a depressed mood. He does not take aspirin on a regular basis. Which of the following is the most reasonable On physical examination, vital signs are normal. BMI management of the antiplatelet therapy? is 29. The remainder of the examination is unremarkable. (A) Stop aspirin (B) Stop aspirin and clopidogrel Which of the following is the most appmpriate management? (C) Stop clopidogrel and add low-dose rivaroxaban (A) Depression screening and treatment (D) Continue aspirin and clopidogrel (B) Low dose aspirin 134

Self-Assessment Test U! €, fl :1 F P o ,\! E UI UI (u UI UI r\t v1 o rrt Jt \', r-r jr il t t tt ii i ITEM 37

r\t v1 o rrt Jt \', r-r jr il t t tt ii i ITEM 37 (C) Smoking cessation counseling and varenicline On physical examination, blood pressure is 108/72 mm (D) Weight loss Hg, pulse rate is 54/min, and respiration rate is 20i min. The remainder of the physical examination is normal. An ECG shows sinus rhythm. A chest radiograph is Item 40 normal. A 56 year-old woman is evaluated before starting treatment with trastuzumab fbrearly stage HER2 positive breast cancer. Which of the following is the most appropriate She has no cardiovascular symptoms and has no exercise management? related limitations. She has hypertension and hyperlipidemia. Medications are losartan and atorvastatin. (A) Addition of clopidogrel On physical examination, vital signs and other flndings (B) Addition of isosorbide mononitrate are normal. The breast surgery site has healed. (C) Coronaryangiography Results of routine laboratory studies are normal. (D) Exercise echocardiography Findings on echocardiogram are normal. Left ventri cular ejection fraction is 55',1,. Item 42 Which of the following is the most appropriate cardiac A 70 year old man is referred fbr evaluation after a 6.1 cm surveillance for this patient? abdominal aortic aneurysm was discoverecl on routine (A) Cardiac magnetic resonance imaging screening ultrasonography. Medical history is significant fbr (B) Echocardiography hypertension and hyperlipidemia. lle has a 50'pack-year (C) Multigated acquisition (MUGA) scan history of cigarette smoking, stopping 6 years ago. Medic:r tions are rosuvastatin and chlorthalidone. (D) No surveillance On physical examination, vital signs are normal. BMI is 28. A bruit is heard over the abdomen, and a pulsatile Item 41 abdominal mass is present to the left of the midline. A 69 year-old man is evaluated for persistent angina despite maximally tolerated antianginal therapy. Symp Which of the following is the most appropriate next step in management? toms appear alter walking less than one half mile and interfere with his quality of life and occupation as a mail (A) Abdominalaortography carrier. He has no pain at rest or heart lailure symptoms. (B) ACE inhibitor therapy He f requently experiences light headedness when arising (C) CT angiography from a seated position. He has a 20 pack year history of smoking but stopped 25 years ago. Medications are aspirin, (D) Open abdominal aortic aneurysm repair metoprolol, sublingual nitroglycerin, and rosuvastatin. (E) Repeat duplex ultrasonography in 6 months

(C) Smoking cessation counseling and varenicline On physical examination, blood pressure is 108/72 mm (D) Weight loss Hg, pulse rate is 54/min, and respiration rate is 20i min. The remainder of the physical examination is normal. An ECG shows sinus rhythm. A chest radiograph is Item 40 normal. A 56 year-old woman is evaluated before starting treatment with trastuzumab fbrearly stage HER2 positive breast cancer. Which of the following is the most appropriate She has no cardiovascular symptoms and has no exercise management? related limitations. She has hypertension and hyperlipidemia. Medications are losartan and atorvastatin. (A) Addition of clopidogrel On physical examination, vital signs and other flndings (B) Addition of isosorbide mononitrate are normal. The breast surgery site has healed. (C) Coronaryangiography Results of routine laboratory studies are normal. (D) Exercise echocardiography Findings on echocardiogram are normal. Left ventri cular ejection fraction is 55',1,. Item 42 Which of the following is the most appropriate cardiac A 70 year old man is referred fbr evaluation after a 6.1 cm surveillance for this patient? abdominal aortic aneurysm was discoverecl on routine (A) Cardiac magnetic resonance imaging screening ultrasonography. Medical history is significant fbr (B) Echocardiography hypertension and hyperlipidemia. lle has a 50'pack-year (C) Multigated acquisition (MUGA) scan history of cigarette smoking, stopping 6 years ago. Medic:r tions are rosuvastatin and chlorthalidone. (D) No surveillance On physical examination, vital signs are normal. BMI is 28. A bruit is heard over the abdomen, and a pulsatile Item 41 abdominal mass is present to the left of the midline. A 69 year-old man is evaluated for persistent angina despite maximally tolerated antianginal therapy. Symp Which of the following is the most appropriate next step in management? toms appear alter walking less than one half mile and interfere with his quality of life and occupation as a mail (A) Abdominalaortography carrier. He has no pain at rest or heart lailure symptoms. (B) ACE inhibitor therapy He f requently experiences light headedness when arising (C) CT angiography from a seated position. He has a 20 pack year history of smoking but stopped 25 years ago. Medications are aspirin, (D) Open abdominal aortic aneurysm repair metoprolol, sublingual nitroglycerin, and rosuvastatin. (E) Repeat duplex ultrasonography in 6 months 135

Self-Assessment Test vr .D Item 43 Which of the following is the most appropriate tre"atment? D Ut UI A S5-year old woman is evaluated for a 6-month history (A) Add ivabradine (D of progressive fatigue and dyspnea while walking on level vr .,I (B) Decreasevalsartan-sacubitril ground. (C) Increasecarvedilol o On physical examination, blood pressure is normal and pulse rate is BO/min. Cardiac examination reveals an open (D) Increase furosemide .D ing snap and a diastolic rumble heard best at the cardiac ur apex. Estimated central venous pressure is normal. A resting echocardiogram shows a left ventricular ejection fraction greater than 55% and a normal size right Item 46 A 75 year old man is evaluated in the emergency depart tr ventricle with preserved function. The mitral valve is thick ment for a 2 day history of left leg pain. The pain started ened and appears rheumatic, with restricted opening of the abruptly and has been constant. He has diabetes mellitus. leaflet tips. The mitral gradient and calculated valve area are hypertension, peripheral artery disease, and hyperlipid consistent with moderate mitral stenosis. emia. Medications are metfbrmin. chlorthalidone. atonla statin. cilostazol. and lor,v dose aspirin. Which of the following is the most appropriate On physical examination, pulse rate is 108'min and management? irrcgular: other vital signs are normal. Cardiac eramina tion reveals an irregularly irregular rhythm. The left lon'er (A) Exerciseechocardiography extremity is cold and mottled. The lelt popliteal and ankle (B) Cardiaccatheterization pulses are absent. Passive range ol motion is normal in the (C) Cardiac magnetic resonance imaging left leg. but the patient has significant pain and is unable to (D) Percutaneousballoon mitralcommissurotomy actively flex the left knee lully. Left leg sensation is intact. The remainder of the physical examination is unremark (E) Transesophagealechocardiography able. ECG shows atrial flbrillation.

vr .D Item 43 Which of the following is the most appropriate tre"atment? D Ut UI A S5-year old woman is evaluated for a 6-month history (A) Add ivabradine (D of progressive fatigue and dyspnea while walking on level vr .,I (B) Decreasevalsartan-sacubitril ground. (C) Increasecarvedilol o On physical examination, blood pressure is normal and pulse rate is BO/min. Cardiac examination reveals an open (D) Increase furosemide .D ing snap and a diastolic rumble heard best at the cardiac ur apex. Estimated central venous pressure is normal. A resting echocardiogram shows a left ventricular ejection fraction greater than 55% and a normal size right Item 46 A 75 year old man is evaluated in the emergency depart tr ventricle with preserved function. The mitral valve is thick ment for a 2 day history of left leg pain. The pain started ened and appears rheumatic, with restricted opening of the abruptly and has been constant. He has diabetes mellitus. leaflet tips. The mitral gradient and calculated valve area are hypertension, peripheral artery disease, and hyperlipid consistent with moderate mitral stenosis. emia. Medications are metfbrmin. chlorthalidone. atonla statin. cilostazol. and lor,v dose aspirin. Which of the following is the most appropriate On physical examination, pulse rate is 108'min and management? irrcgular: other vital signs are normal. Cardiac eramina tion reveals an irregularly irregular rhythm. The left lon'er (A) Exerciseechocardiography extremity is cold and mottled. The lelt popliteal and ankle (B) Cardiaccatheterization pulses are absent. Passive range ol motion is normal in the (C) Cardiac magnetic resonance imaging left leg. but the patient has significant pain and is unable to (D) Percutaneousballoon mitralcommissurotomy actively flex the left knee lully. Left leg sensation is intact. The remainder of the physical examination is unremark (E) Transesophagealechocardiography able. ECG shows atrial flbrillation. tr Item 44 A74 year old man is evaluated in the emergency depart Which of the following is the most appropriate next step in management? ment fbr somnolence. He resides in a skilled nursing lacility. His transfer note indicates that he has moderately severe (A) Angiography Alzheimer disease treated with donepezil. (ts) Apixaban On physical examination, bktod pressure is 70i 40 mm (C) Intravenoustenecteplase tlg and pulse rate is 30/min; other vital signs are normal. (D) Unlirrt'tionated heparin Oxygen saturation with the patient breathing ambient air is 97"/,,.The patient is diflicult to arouse. Cardiac eramination (E) Venous duplex ultrasonography reveals bradycardia but is otherwise unremarkable. Complete blood count and electrolyte levels are nor ma[. Cardiac telemetry shows sinus bradycardia with heart Item 47 A 28 year <,rldwoman is evaluated in the emergency depart tr rate ol30/min. mcnt for substernal chest tightness that started several hours ago. She is 2 weeks postpartum after an uncomplicated preg Which of the following is the most appropriate treatment? nancy and delivery. She has no history of cardiopuhnonary disease and has no risk factors for atherosclerotic cardiovas (A) Amiodarone cular disease. (B) Chest compressions On physical examination. blood pressure is 122i72 mm (C) lntravenousatropine I Ig in both arms. pulse rate is 90i min and regular. and respi (D) Isoproterenol ration rate is 24'min. The estimated central venous pressure and apical impulse are normal. An S.r is present. The rest of' thc examination is unremarkable. Item 45 Laboratory studies are significant for an elevated A 78 year old woman is evaluated for a 3-month history of high sensitivity cardiac troponin level (>99th percentile heart failure with reduced ejection fraction (ejection frac upper ref'erence limit). tion, 20%). She has stable dyspnea when walking up stairs An ECG shou,s ST segment elevation in the anterior but has no other symptoms. Her medical history is other precordial leads. An echocardiogram shows anterior wall wise unremarkable. Medications are valsartan-sacubitril, hypokinesis. Estimated ejection fiaction is,10'iI,. carvedilol, furosemide, and spironolactone. Carvedilol is at half maximum dosage; all other medications are at maxi- Which of the following is the most likely diagnosis? mum recommended dosages. (A) Atheroscleroticplaque rupture On physical examination, blood pressure is 118/74 mm (B) Peripartum cardionryopathy Hg and pulse rate is 88/min. BMI is 27, unchanged from her last visit. Central venous pressure and the remainder of the (C) Spontaneous coronary artery dissection examination are normal. (D) Stress induced (takotsubo) cardiomyopathy

tr Item 44 A74 year old man is evaluated in the emergency depart Which of the following is the most appropriate next step in management? ment fbr somnolence. He resides in a skilled nursing lacility. His transfer note indicates that he has moderately severe (A) Angiography Alzheimer disease treated with donepezil. (ts) Apixaban On physical examination, bktod pressure is 70i 40 mm (C) Intravenoustenecteplase tlg and pulse rate is 30/min; other vital signs are normal. (D) Unlirrt'tionated heparin Oxygen saturation with the patient breathing ambient air is 97"/,,.The patient is diflicult to arouse. Cardiac eramination (E) Venous duplex ultrasonography reveals bradycardia but is otherwise unremarkable. Complete blood count and electrolyte levels are nor ma[. Cardiac telemetry shows sinus bradycardia with heart Item 47 A 28 year <,rldwoman is evaluated in the emergency depart tr rate ol30/min. mcnt for substernal chest tightness that started several hours ago. She is 2 weeks postpartum after an uncomplicated preg Which of the following is the most appropriate treatment? nancy and delivery. She has no history of cardiopuhnonary disease and has no risk factors for atherosclerotic cardiovas (A) Amiodarone cular disease. (B) Chest compressions On physical examination. blood pressure is 122i72 mm (C) lntravenousatropine I Ig in both arms. pulse rate is 90i min and regular. and respi (D) Isoproterenol ration rate is 24'min. The estimated central venous pressure and apical impulse are normal. An S.r is present. The rest of' thc examination is unremarkable. Item 45 Laboratory studies are significant for an elevated A 78 year old woman is evaluated for a 3-month history of high sensitivity cardiac troponin level (>99th percentile heart failure with reduced ejection fraction (ejection frac upper ref'erence limit). tion, 20%). She has stable dyspnea when walking up stairs An ECG shou,s ST segment elevation in the anterior but has no other symptoms. Her medical history is other precordial leads. An echocardiogram shows anterior wall wise unremarkable. Medications are valsartan-sacubitril, hypokinesis. Estimated ejection fiaction is,10'iI,. carvedilol, furosemide, and spironolactone. Carvedilol is at half maximum dosage; all other medications are at maxi- Which of the following is the most likely diagnosis? mum recommended dosages. (A) Atheroscleroticplaque rupture On physical examination, blood pressure is 118/74 mm (B) Peripartum cardionryopathy Hg and pulse rate is 88/min. BMI is 27, unchanged from her last visit. Central venous pressure and the remainder of the (C) Spontaneous coronary artery dissection examination are normal. (D) Stress induced (takotsubo) cardiomyopathy 136

Self-Assessment Test Ut G' tr Item 48 A 42 year old man is evaluated in tl-re emergency deparl Which of the following is the most appropriate treatment? (A) Additionofvalsartan-sacubitril l- o ment lbr sudden onset right sided weakness. His symp (B) Implantable cardioverter-deflbrillator therapy tonrs resolved fully over the past hour. Ilc has no knowr.r t=l (C) Replacement of metoprolol with carvedilol tt medical problems ar.rd takes no meclications. o t On pl.rysical examination, vital signs are norntal. llis (D) Septal reduction therapy l,! heart rhythm is regular. Ner-rrologic cxamination is normal. No carotid bruits <.rr heart murmurs are noted. t o Laboratttry stud)/ results are normal. Magnctic resonance angiogram of the brain demon Item 51 A 73 year old m:rn is evaluated in the emergency depart tr strates a snrall left sided ischemic stroke but no other ment for a 2 hour history ol crushing chest pain and dia iesions. ECC, carotid ultrasouncl, telemetry, and lower plroresis. An admission EC(l is shown. extremity ultrasouncl are nrtnnal. A transesophagcal echo cardiogranr demonstrates a patent fbramen ovale (PFO) with right to left shunt noted with cough and Valsalva release. No other abnormalities are identified.

tr Item 48 A 42 year old man is evaluated in tl-re emergency deparl Which of the following is the most appropriate treatment? (A) Additionofvalsartan-sacubitril l- o ment lbr sudden onset right sided weakness. His symp (B) Implantable cardioverter-deflbrillator therapy tonrs resolved fully over the past hour. Ilc has no knowr.r t=l (C) Replacement of metoprolol with carvedilol tt medical problems ar.rd takes no meclications. o t On pl.rysical examination, vital signs are norntal. llis (D) Septal reduction therapy l,! heart rhythm is regular. Ner-rrologic cxamination is normal. No carotid bruits <.rr heart murmurs are noted. t o Laboratttry stud)/ results are normal. Magnctic resonance angiogram of the brain demon Item 51 A 73 year old m:rn is evaluated in the emergency depart tr strates a snrall left sided ischemic stroke but no other ment for a 2 hour history ol crushing chest pain and dia iesions. ECC, carotid ultrasouncl, telemetry, and lower plroresis. An admission EC(l is shown. extremity ultrasouncl are nrtnnal. A transesophagcal echo cardiogranr demonstrates a patent fbramen ovale (PFO) with right to left shunt noted with cough and Valsalva release. No other abnormalities are identified. Which of the following is the most appropriate v2 management? (A) Aspirin (B) PIrO device cl<tsure Iu V3

tr Item 48 A 42 year old man is evaluated in tl-re emergency deparl Which of the following is the most appropriate treatment? (A) Additionofvalsartan-sacubitril l- o ment lbr sudden onset right sided weakness. His symp (B) Implantable cardioverter-deflbrillator therapy tonrs resolved fully over the past hour. Ilc has no knowr.r t=l (C) Replacement of metoprolol with carvedilol tt medical problems ar.rd takes no meclications. o t On pl.rysical examination, vital signs are norntal. llis (D) Septal reduction therapy l,! heart rhythm is regular. Ner-rrologic cxamination is normal. No carotid bruits <.rr heart murmurs are noted. t o Laboratttry stud)/ results are normal. Magnctic resonance angiogram of the brain demon Item 51 A 73 year old m:rn is evaluated in the emergency depart tr strates a snrall left sided ischemic stroke but no other ment for a 2 hour history ol crushing chest pain and dia iesions. ECC, carotid ultrasouncl, telemetry, and lower plroresis. An admission EC(l is shown. extremity ultrasouncl are nrtnnal. A transesophagcal echo cardiogranr demonstrates a patent fbramen ovale (PFO) with right to left shunt noted with cough and Valsalva release. No other abnormalities are identified. Which of the following is the most appropriate v2 management? (A) Aspirin (B) PIrO device cl<tsure Iu V3 (C) Warf arin (D) Observation

tr Item 48 A 42 year old man is evaluated in tl-re emergency deparl Which of the following is the most appropriate treatment? (A) Additionofvalsartan-sacubitril l- o ment lbr sudden onset right sided weakness. His symp (B) Implantable cardioverter-deflbrillator therapy tonrs resolved fully over the past hour. Ilc has no knowr.r t=l (C) Replacement of metoprolol with carvedilol tt medical problems ar.rd takes no meclications. o t On pl.rysical examination, vital signs are norntal. llis (D) Septal reduction therapy l,! heart rhythm is regular. Ner-rrologic cxamination is normal. No carotid bruits <.rr heart murmurs are noted. t o Laboratttry stud)/ results are normal. Magnctic resonance angiogram of the brain demon Item 51 A 73 year old m:rn is evaluated in the emergency depart tr strates a snrall left sided ischemic stroke but no other ment for a 2 hour history ol crushing chest pain and dia iesions. ECC, carotid ultrasouncl, telemetry, and lower plroresis. An admission EC(l is shown. extremity ultrasouncl are nrtnnal. A transesophagcal echo cardiogranr demonstrates a patent fbramen ovale (PFO) with right to left shunt noted with cough and Valsalva release. No other abnormalities are identified. Which of the following is the most appropriate v2 management? (A) Aspirin (B) PIrO device cl<tsure Iu V3 (C) Warf arin (D) Observation Item 49 A 49 year-old woman is evaluated during a new patient visit. She has no medical problems or concerning symptoms and takes no medications. On physical examination, vital signs are normal. The t5

Which of the following is the most appropriate v2 management? (A) Aspirin (B) PIrO device cl<tsure Iu V3 (C) Warf arin (D) Observation Item 49 A 49 year-old woman is evaluated during a new patient visit. She has no medical problems or concerning symptoms and takes no medications. On physical examination, vital signs are normal. The t5 S, is diminished, and there is an aortic ejection click shortly after the S,. The S, is normal. There is a grade 216,high- pitched, decrescendo early diastolic murmur heard best at A drug eluting stent is placed in the proximal right cor the left sternal border. The murmur is accentuated when the onary artery, and he is transf'erred to the coronary care unit. patient leans forward. On physical examination, blood pressure is 80/50 mm Hg. pulse rate is 120/min, respiration rate is 22lmin, and Which ofthe following is the most appropriate diagnostic test? oxygen saturatior.r is 94'X, rvith the patient breathing ambient (A) Cardiac catheterization air. An S., is heard; there is no pericardial rub. Central venous pressure is clevated.'lhe lungs are clear to auscultation. (B) Cardiac magnetic resonance imaging (C) Stressechocardiography Which of the following is the most appropriate treatment? (D) Transesophagealechocardiography (E) Transthoracicechocardiography (A) Intra aortic balloon pump placement (B) lntravenous dobutanrine (C) [ntravenous 0.9'], saline Item 50 (D) Oral metoprolol A 42 year old man is evaluated for dyspnea that occurs while walking on a flat surface and causes him to stop when walking uphill. He has hypertrophic cardiomyopa, thy, which was diagnosed at age 38 years. He has no other Item 52 An B4-year old man is evaluated before hospital discharge tr symptoms and has no family history of sudden cardiac following an exacerbation of heart failure. Ile has an death. Medications are metoprolol and disopyramide. implantablc cardioverter deflbrillator. Medications are lis An echocardiogram shows asymmetric septal hyper inopril, lurosemicle, carvedilol, and spironolactone. I)uring trophy with maximal septal thickness of 24 mm. Systolic hospitalization, the patient received intravenous Iurose anterior motion of the mitral valve is present with dynamic micle at a dosage twice that of his home oral dosage. left ventricular outflow tract obstruction and peak gradient On physical examination. vital signs are normal. BMI of 64 mm Hg at rest. is 28. Centralvenous pressure is not elevated. 'lhere is no S.,, Six months ago, 24-hour ECG monitoring performed and there are no pulmonary crackles. as part ofsurveillance showed sinus bradycardia and single Serum creatinine level has returnecl to the baseline premature ventricular contractions averaging 6 per hour. level, and clectrolytes are normal.

S, is diminished, and there is an aortic ejection click shortly after the S,. The S, is normal. There is a grade 216,high- pitched, decrescendo early diastolic murmur heard best at A drug eluting stent is placed in the proximal right cor the left sternal border. The murmur is accentuated when the onary artery, and he is transf'erred to the coronary care unit. patient leans forward. On physical examination, blood pressure is 80/50 mm Hg. pulse rate is 120/min, respiration rate is 22lmin, and Which ofthe following is the most appropriate diagnostic test? oxygen saturatior.r is 94'X, rvith the patient breathing ambient (A) Cardiac catheterization air. An S., is heard; there is no pericardial rub. Central venous pressure is clevated.'lhe lungs are clear to auscultation. (B) Cardiac magnetic resonance imaging (C) Stressechocardiography Which of the following is the most appropriate treatment? (D) Transesophagealechocardiography (E) Transthoracicechocardiography (A) Intra aortic balloon pump placement (B) lntravenous dobutanrine (C) [ntravenous 0.9'], saline Item 50 (D) Oral metoprolol A 42 year old man is evaluated for dyspnea that occurs while walking on a flat surface and causes him to stop when walking uphill. He has hypertrophic cardiomyopa, thy, which was diagnosed at age 38 years. He has no other Item 52 An B4-year old man is evaluated before hospital discharge tr symptoms and has no family history of sudden cardiac following an exacerbation of heart failure. Ile has an death. Medications are metoprolol and disopyramide. implantablc cardioverter deflbrillator. Medications are lis An echocardiogram shows asymmetric septal hyper inopril, lurosemicle, carvedilol, and spironolactone. I)uring trophy with maximal septal thickness of 24 mm. Systolic hospitalization, the patient received intravenous Iurose anterior motion of the mitral valve is present with dynamic micle at a dosage twice that of his home oral dosage. left ventricular outflow tract obstruction and peak gradient On physical examination. vital signs are normal. BMI of 64 mm Hg at rest. is 28. Centralvenous pressure is not elevated. 'lhere is no S.,, Six months ago, 24-hour ECG monitoring performed and there are no pulmonary crackles. as part ofsurveillance showed sinus bradycardia and single Serum creatinine level has returnecl to the baseline premature ventricular contractions averaging 6 per hour. level, and clectrolytes are normal. 137

Self-Assessment Test tt .D 1I| Echocardiogram from this hospitalization shows fbrce her to stop several times. Medical history is otherwise UI EJ ejection fraction of 25'1, rn'ith left ventricular end cliastolic signiflcant for hypertension and hyperlipidemia. She has a l,l coNi dimension of 72 mm. 50 pack year smoking history but quit 10 years ago. Medi lD la (,l cations are aspirin, cilostazol, lisinopril, and amlodipine. She Which of the following is most likely to prevent early was prescribed atorvastatin, but she took the medication for (D hospital readmission in this patient? only 1 week after reading that muscle ache is an adverse effect.

tt .D 1I| Echocardiogram from this hospitalization shows fbrce her to stop several times. Medical history is otherwise UI EJ ejection fraction of 25'1, rn'ith left ventricular end cliastolic signiflcant for hypertension and hyperlipidemia. She has a l,l coNi dimension of 72 mm. 50 pack year smoking history but quit 10 years ago. Medi lD la (,l cations are aspirin, cilostazol, lisinopril, and amlodipine. She Which of the following is most likely to prevent early was prescribed atorvastatin, but she took the medication for (D hospital readmission in this patient? only 1 week after reading that muscle ache is an adverse effect. .D (A) Echocardiograpl.ry in 3 rnor.rths Which of the following is the most appropriate treatment? Ut (B) Follorn, up officc visit in 30 days (C) Folkrw up telephone call in 2 clays (A) Atorvastatin (D) Decrease in turoscmide to original hclme dosage (B) Colestipol (C) Ezetimibe (D) Icosapent ethyl Item 53 A 75 year old man is evaluated for dyspnea and an episode of exertional syncope. He is diagnosed on clinical examina- Item 55 tion with aortic stenosis. A 45-year old woman is evaluated in the office for palpita An ECG shows normal sinus rhythm and left ventricular tions. She has no other symptoms at rest or with exertion. hypertrophy with repolarization abnormalities. The echo The palpations make her anxious and are intolerable. They cardiogram reveals a severely thickened, minimally mobile seem to subside with exercise and at night. She does not tricuspid aortic valve compatible with severe aortic stenosis. smoke cigarettes or drink alcohol or caffeinated beverages, However, hemodynamic data from echocardiography show and she has no other pertinent personal or family history. a mean aortic gradient and aortic valve area consistent with She takes no medications. moderate aortic stenosis. Left ventricular ejection fraction is On physical examination, pulse rate is 65/min and greater than 55%, and stroke volume index is normal. irregular; other vital signs are normal. Heart sounds are reg ular, with premature beats associated with cannon o waves Which of the following is the most appropriate next step in on neck examination. The remainder of the examination is management? unremarkable. (A) Cardiac catheterization Laboratory studies, including complete blood count and thyroid stimulating hormone level, are normal. Preg (B) CToftheaorticvalve nancy test results are negative. (C) Exercise stress testing ECG is shown. Echocardiogram is normal. (D) Surgical aortic valve replacement (E) Transcatheter aortic valve implantation Whichofthe following is the most appropriate management? (A) Amiodarone Item 54 (B) Exercise ECG A 70 year old woman is evaluated in follow up for peripheral (C) Propranolol artery disease. She walks 2 miles daily, and her symptoms (D) Reassurance

.D (A) Echocardiograpl.ry in 3 rnor.rths Which of the following is the most appropriate treatment? Ut (B) Follorn, up officc visit in 30 days (C) Folkrw up telephone call in 2 clays (A) Atorvastatin (D) Decrease in turoscmide to original hclme dosage (B) Colestipol (C) Ezetimibe (D) Icosapent ethyl Item 53 A 75 year old man is evaluated for dyspnea and an episode of exertional syncope. He is diagnosed on clinical examina- Item 55 tion with aortic stenosis. A 45-year old woman is evaluated in the office for palpita An ECG shows normal sinus rhythm and left ventricular tions. She has no other symptoms at rest or with exertion. hypertrophy with repolarization abnormalities. The echo The palpations make her anxious and are intolerable. They cardiogram reveals a severely thickened, minimally mobile seem to subside with exercise and at night. She does not tricuspid aortic valve compatible with severe aortic stenosis. smoke cigarettes or drink alcohol or caffeinated beverages, However, hemodynamic data from echocardiography show and she has no other pertinent personal or family history. a mean aortic gradient and aortic valve area consistent with She takes no medications. moderate aortic stenosis. Left ventricular ejection fraction is On physical examination, pulse rate is 65/min and greater than 55%, and stroke volume index is normal. irregular; other vital signs are normal. Heart sounds are reg ular, with premature beats associated with cannon o waves Which of the following is the most appropriate next step in on neck examination. The remainder of the examination is management? unremarkable. (A) Cardiac catheterization Laboratory studies, including complete blood count and thyroid stimulating hormone level, are normal. Preg (B) CToftheaorticvalve nancy test results are negative. (C) Exercise stress testing ECG is shown. Echocardiogram is normal. (D) Surgical aortic valve replacement (E) Transcatheter aortic valve implantation Whichofthe following is the most appropriate management? (A) Amiodarone Item 54 (B) Exercise ECG A 70 year old woman is evaluated in follow up for peripheral (C) Propranolol artery disease. She walks 2 miles daily, and her symptoms (D) Reassurance aVFl VI v4

.D (A) Echocardiograpl.ry in 3 rnor.rths Which of the following is the most appropriate treatment? Ut (B) Follorn, up officc visit in 30 days (C) Folkrw up telephone call in 2 clays (A) Atorvastatin (D) Decrease in turoscmide to original hclme dosage (B) Colestipol (C) Ezetimibe (D) Icosapent ethyl Item 53 A 75 year old man is evaluated for dyspnea and an episode of exertional syncope. He is diagnosed on clinical examina- Item 55 tion with aortic stenosis. A 45-year old woman is evaluated in the office for palpita An ECG shows normal sinus rhythm and left ventricular tions. She has no other symptoms at rest or with exertion. hypertrophy with repolarization abnormalities. The echo The palpations make her anxious and are intolerable. They cardiogram reveals a severely thickened, minimally mobile seem to subside with exercise and at night. She does not tricuspid aortic valve compatible with severe aortic stenosis. smoke cigarettes or drink alcohol or caffeinated beverages, However, hemodynamic data from echocardiography show and she has no other pertinent personal or family history. a mean aortic gradient and aortic valve area consistent with She takes no medications. moderate aortic stenosis. Left ventricular ejection fraction is On physical examination, pulse rate is 65/min and greater than 55%, and stroke volume index is normal. irregular; other vital signs are normal. Heart sounds are reg ular, with premature beats associated with cannon o waves Which of the following is the most appropriate next step in on neck examination. The remainder of the examination is management? unremarkable. (A) Cardiac catheterization Laboratory studies, including complete blood count and thyroid stimulating hormone level, are normal. Preg (B) CToftheaorticvalve nancy test results are negative. (C) Exercise stress testing ECG is shown. Echocardiogram is normal. (D) Surgical aortic valve replacement (E) Transcatheter aortic valve implantation Whichofthe following is the most appropriate management? (A) Amiodarone Item 54 (B) Exercise ECG A 70 year old woman is evaluated in follow up for peripheral (C) Propranolol artery disease. She walks 2 miles daily, and her symptoms (D) Reassurance aVFl VI v4 lt aVl- v? v5

.D (A) Echocardiograpl.ry in 3 rnor.rths Which of the following is the most appropriate treatment? Ut (B) Follorn, up officc visit in 30 days (C) Folkrw up telephone call in 2 clays (A) Atorvastatin (D) Decrease in turoscmide to original hclme dosage (B) Colestipol (C) Ezetimibe (D) Icosapent ethyl Item 53 A 75 year old man is evaluated for dyspnea and an episode of exertional syncope. He is diagnosed on clinical examina- Item 55 tion with aortic stenosis. A 45-year old woman is evaluated in the office for palpita An ECG shows normal sinus rhythm and left ventricular tions. She has no other symptoms at rest or with exertion. hypertrophy with repolarization abnormalities. The echo The palpations make her anxious and are intolerable. They cardiogram reveals a severely thickened, minimally mobile seem to subside with exercise and at night. She does not tricuspid aortic valve compatible with severe aortic stenosis. smoke cigarettes or drink alcohol or caffeinated beverages, However, hemodynamic data from echocardiography show and she has no other pertinent personal or family history. a mean aortic gradient and aortic valve area consistent with She takes no medications. moderate aortic stenosis. Left ventricular ejection fraction is On physical examination, pulse rate is 65/min and greater than 55%, and stroke volume index is normal. irregular; other vital signs are normal. Heart sounds are reg ular, with premature beats associated with cannon o waves Which of the following is the most appropriate next step in on neck examination. The remainder of the examination is management? unremarkable. (A) Cardiac catheterization Laboratory studies, including complete blood count and thyroid stimulating hormone level, are normal. Preg (B) CToftheaorticvalve nancy test results are negative. (C) Exercise stress testing ECG is shown. Echocardiogram is normal. (D) Surgical aortic valve replacement (E) Transcatheter aortic valve implantation Whichofthe following is the most appropriate management? (A) Amiodarone Item 54 (B) Exercise ECG A 70 year old woman is evaluated in follow up for peripheral (C) Propranolol artery disease. She walks 2 miles daily, and her symptoms (D) Reassurance aVFl VI v4 lt aVl- v? v5 ilt aVF V3 W

.D (A) Echocardiograpl.ry in 3 rnor.rths Which of the following is the most appropriate treatment? Ut (B) Follorn, up officc visit in 30 days (C) Folkrw up telephone call in 2 clays (A) Atorvastatin (D) Decrease in turoscmide to original hclme dosage (B) Colestipol (C) Ezetimibe (D) Icosapent ethyl Item 53 A 75 year old man is evaluated for dyspnea and an episode of exertional syncope. He is diagnosed on clinical examina- Item 55 tion with aortic stenosis. A 45-year old woman is evaluated in the office for palpita An ECG shows normal sinus rhythm and left ventricular tions. She has no other symptoms at rest or with exertion. hypertrophy with repolarization abnormalities. The echo The palpations make her anxious and are intolerable. They cardiogram reveals a severely thickened, minimally mobile seem to subside with exercise and at night. She does not tricuspid aortic valve compatible with severe aortic stenosis. smoke cigarettes or drink alcohol or caffeinated beverages, However, hemodynamic data from echocardiography show and she has no other pertinent personal or family history. a mean aortic gradient and aortic valve area consistent with She takes no medications. moderate aortic stenosis. Left ventricular ejection fraction is On physical examination, pulse rate is 65/min and greater than 55%, and stroke volume index is normal. irregular; other vital signs are normal. Heart sounds are reg ular, with premature beats associated with cannon o waves Which of the following is the most appropriate next step in on neck examination. The remainder of the examination is management? unremarkable. (A) Cardiac catheterization Laboratory studies, including complete blood count and thyroid stimulating hormone level, are normal. Preg (B) CToftheaorticvalve nancy test results are negative. (C) Exercise stress testing ECG is shown. Echocardiogram is normal. (D) Surgical aortic valve replacement (E) Transcatheter aortic valve implantation Whichofthe following is the most appropriate management? (A) Amiodarone Item 54 (B) Exercise ECG A 70 year old woman is evaluated in follow up for peripheral (C) Propranolol artery disease. She walks 2 miles daily, and her symptoms (D) Reassurance aVFl VI v4 lt aVl- v? v5 ilt aVF V3 W :l ITEM 55

.D (A) Echocardiograpl.ry in 3 rnor.rths Which of the following is the most appropriate treatment? Ut (B) Follorn, up officc visit in 30 days (C) Folkrw up telephone call in 2 clays (A) Atorvastatin (D) Decrease in turoscmide to original hclme dosage (B) Colestipol (C) Ezetimibe (D) Icosapent ethyl Item 53 A 75 year old man is evaluated for dyspnea and an episode of exertional syncope. He is diagnosed on clinical examina- Item 55 tion with aortic stenosis. A 45-year old woman is evaluated in the office for palpita An ECG shows normal sinus rhythm and left ventricular tions. She has no other symptoms at rest or with exertion. hypertrophy with repolarization abnormalities. The echo The palpations make her anxious and are intolerable. They cardiogram reveals a severely thickened, minimally mobile seem to subside with exercise and at night. She does not tricuspid aortic valve compatible with severe aortic stenosis. smoke cigarettes or drink alcohol or caffeinated beverages, However, hemodynamic data from echocardiography show and she has no other pertinent personal or family history. a mean aortic gradient and aortic valve area consistent with She takes no medications. moderate aortic stenosis. Left ventricular ejection fraction is On physical examination, pulse rate is 65/min and greater than 55%, and stroke volume index is normal. irregular; other vital signs are normal. Heart sounds are reg ular, with premature beats associated with cannon o waves Which of the following is the most appropriate next step in on neck examination. The remainder of the examination is management? unremarkable. (A) Cardiac catheterization Laboratory studies, including complete blood count and thyroid stimulating hormone level, are normal. Preg (B) CToftheaorticvalve nancy test results are negative. (C) Exercise stress testing ECG is shown. Echocardiogram is normal. (D) Surgical aortic valve replacement (E) Transcatheter aortic valve implantation Whichofthe following is the most appropriate management? (A) Amiodarone Item 54 (B) Exercise ECG A 70 year old woman is evaluated in follow up for peripheral (C) Propranolol artery disease. She walks 2 miles daily, and her symptoms (D) Reassurance aVFl VI v4 lt aVl- v? v5 ilt aVF V3 W :l ITEM 55 l 138 ! ;

Self-Assessment Test ta Item 55 Ou chesl. raclkrgrullh, stcnrotoltl\ uilcs :rnri vasci-rhr (, A 35 year-old man is evaluated for exertional dyspnea. His clips are seen. irnd snrall bihte rai plcr.rr:li cf lirsious l"c pn se n1" (u history is otherwise unremarkable. On physical examination, vital signs and oxygen sat- Which of the following is the most likell, cliagnosisl' ta Ut uration are normal. Central venous pressure is elevated. (A) Cardiac tirmponrlclc {, t A left parasternal impulse is present. A grade 2/6 systolic t (B) Chronic live r diseasc murmur is heard at the second left intercostal space, and a diastolic flow rumble is heard at the left sternal border. (C) Constrictive pericartlitis c, t/t Fixed splitting of the S, is present. The remainder of the (D) Itestrictive crrrtlior.nvop;rthv physical examination is normal. An ECG demonstrates sinus rhythm with right axis deviation and incomplete right bundle branch block. A Item 59 transthoracic echocardiogram demonstrates a 1.5 cm A 65 year olcl ntatr is evlltt;t l er-l li ir rr 2 ti:tr' lr ir t r.rr_l. ol srlcrlr l ostium secundum atrial septal defect, with moderate right episocles of chest clisctltrt[irrt rrntl d1,s1lr-rc';r ()!:ci.lri'in! iti-,lh ;l heart enlargement. Left ventricular cavity size and function rr'st and n'itlt e.rcrtion. I'orlir-r, lrr prtjsr,rrn rr-!lh :i holrrs rrl' are normal. the estimated right ventricular systolic pressure persislerll severt' ccntral ehi:sl prrssurc. is 30 mm Hg. On ph1'sicaIerantirtlIion. Irlood Jr-r-,ssrilr.ii I55 9{.} il}lt IIg. pttlse rille is 9(-).n1in. r'csllirrrlion nilc is l.l(l rnin.:,urri Which of the following is the most appropriate oxygen saturdtioll is 9:l'i, \\'ilh thc l)rtir,11l brcething ri;thi management? ent air. UNll is 29. .\n S, is prcscnt. llul llrr rrri.rilritr-ll'1lrc carcliac erarninlliorr is nonn;rl. (A) Atrial septal defect closure liigh scnsitivilr' clrrli.rc l roplnin lt'r'rl ir ,,'lr:r';rtr'el (B) Cardiopulmonaryexercisetesting (>991h percenlile trppe r rclcrcrrce limil). (C) Coronaryangiography An L-(l(l is shou'u. (D) Echocardiographicsurveillance

ta Item 55 Ou chesl. raclkrgrullh, stcnrotoltl\ uilcs :rnri vasci-rhr (, A 35 year-old man is evaluated for exertional dyspnea. His clips are seen. irnd snrall bihte rai plcr.rr:li cf lirsious l"c pn se n1" (u history is otherwise unremarkable. On physical examination, vital signs and oxygen sat- Which of the following is the most likell, cliagnosisl' ta Ut uration are normal. Central venous pressure is elevated. (A) Cardiac tirmponrlclc {, t A left parasternal impulse is present. A grade 2/6 systolic t (B) Chronic live r diseasc murmur is heard at the second left intercostal space, and a diastolic flow rumble is heard at the left sternal border. (C) Constrictive pericartlitis c, t/t Fixed splitting of the S, is present. The remainder of the (D) Itestrictive crrrtlior.nvop;rthv physical examination is normal. An ECG demonstrates sinus rhythm with right axis deviation and incomplete right bundle branch block. A Item 59 transthoracic echocardiogram demonstrates a 1.5 cm A 65 year olcl ntatr is evlltt;t l er-l li ir rr 2 ti:tr' lr ir t r.rr_l. ol srlcrlr l ostium secundum atrial septal defect, with moderate right episocles of chest clisctltrt[irrt rrntl d1,s1lr-rc';r ()!:ci.lri'in! iti-,lh ;l heart enlargement. Left ventricular cavity size and function rr'st and n'itlt e.rcrtion. I'orlir-r, lrr prtjsr,rrn rr-!lh :i holrrs rrl' are normal. the estimated right ventricular systolic pressure persislerll severt' ccntral ehi:sl prrssurc. is 30 mm Hg. On ph1'sicaIerantirtlIion. Irlood Jr-r-,ssrilr.ii I55 9{.} il}lt IIg. pttlse rille is 9(-).n1in. r'csllirrrlion nilc is l.l(l rnin.:,urri Which of the following is the most appropriate oxygen saturdtioll is 9:l'i, \\'ilh thc l)rtir,11l brcething ri;thi management? ent air. UNll is 29. .\n S, is prcscnt. llul llrr rrri.rilritr-ll'1lrc carcliac erarninlliorr is nonn;rl. (A) Atrial septal defect closure liigh scnsitivilr' clrrli.rc l roplnin lt'r'rl ir ,,'lr:r';rtr'el (B) Cardiopulmonaryexercisetesting (>991h percenlile trppe r rclcrcrrce limil). (C) Coronaryangiography An L-(l(l is shou'u. (D) Echocardiographicsurveillance tr Item 57 A 71-year-old man is evaluated fbr a 6-month history of exertional chest pain. lhe pain has incre:rsed in {iequency and now occurs earlier during his exercise regimen. Jhe pain is relieved by subiingual nitroglycerin. He underwent coronary artery bypass gralt surgery 4 years ago. History is also signiflcant fbr hypertension and hyperlipidemia. Medi- cations are metoprolol, Iisinopril, atorvastatin, and aspirin. Physical examination findings, ir-rcluding vital signs, are normal. ECG shows left bundle branch block.

tr Item 57 A 71-year-old man is evaluated fbr a 6-month history of exertional chest pain. lhe pain has incre:rsed in {iequency and now occurs earlier during his exercise regimen. Jhe pain is relieved by subiingual nitroglycerin. He underwent coronary artery bypass gralt surgery 4 years ago. History is also signiflcant fbr hypertension and hyperlipidemia. Medi- cations are metoprolol, Iisinopril, atorvastatin, and aspirin. Physical examination findings, ir-rcluding vital signs, are normal. ECG shows left bundle branch block. Which of the following is the most appropriate test? (A) Dobutamine echocardiography (B) Exercise ECG (C) Exercise single photon emission CT (D) Vasodilator single-photon emission CT He is given lspirin. c'L4rickrgrcl. ilrtr.l\j(rlotls illtfi-tL tionated heparitr. lncl a nitt-ogl_\'ccrir.l iillllsi{rtt, llir t'hi'st pain initiirlll. inrprovcs hut rt'turns dr:piie tiilrt:dl-r'L:i'ritt tr Item 58 A74 year old manisevaluatedinthehospitirl fbra 6 month infusion ancl rnorph i ne. history ofprogressive fatigue and exertional dyspnea. along Which of the following is the most appropriate managenrent? with increasing peripheral edema and abdominal girth ] over the past 3 months. IJe also has corouary artery dis (A) t'.cltoc:trcliographl' ease, fbr which he had a coronary artery bypass gral't at age (13) F.plerenone 62 years. Medications are metoprolol, 1ow-dose aspirin. and (C) O.xygen pcr ttrrsal cal11ltll.t atorvastatin. On physical examination. vital signs are normal. Jugtt (D) Urgent (orollilr! angir.,grrplr-'"' lar venous distention with prominent waveforms is noted' There is no discernable fall in the central venous pressure during inspiration. An early diastolic sound is present. Item 60 The liver is enlarged and pulsatile. Ascites is present, and A 26-year-old woman is evaluated for palpitations that peripheral edema extends to the knees bilaterally. began 2 months ago. The palpitations begin with no speciflc

Which of the following is the most appropriate test? (A) Dobutamine echocardiography (B) Exercise ECG (C) Exercise single photon emission CT (D) Vasodilator single-photon emission CT He is given lspirin. c'L4rickrgrcl. ilrtr.l\j(rlotls illtfi-tL tionated heparitr. lncl a nitt-ogl_\'ccrir.l iillllsi{rtt, llir t'hi'st pain initiirlll. inrprovcs hut rt'turns dr:piie tiilrt:dl-r'L:i'ritt tr Item 58 A74 year old manisevaluatedinthehospitirl fbra 6 month infusion ancl rnorph i ne. history ofprogressive fatigue and exertional dyspnea. along Which of the following is the most appropriate managenrent? with increasing peripheral edema and abdominal girth ] over the past 3 months. IJe also has corouary artery dis (A) t'.cltoc:trcliographl' ease, fbr which he had a coronary artery bypass gral't at age (13) F.plerenone 62 years. Medications are metoprolol, 1ow-dose aspirin. and (C) O.xygen pcr ttrrsal cal11ltll.t atorvastatin. On physical examination. vital signs are normal. Jugtt (D) Urgent (orollilr! angir.,grrplr-'"' lar venous distention with prominent waveforms is noted' There is no discernable fall in the central venous pressure during inspiration. An early diastolic sound is present. Item 60 The liver is enlarged and pulsatile. Ascites is present, and A 26-year-old woman is evaluated for palpitations that peripheral edema extends to the knees bilaterally. began 2 months ago. The palpitations begin with no speciflc 139

: 1 Self-Assessment Test : t/r (D inciting factors, Iast 5 to 15 minutes, and are alleviated by Chest radiograph reveals a widened mediastinum, and rest or deep breathing. Ihey occur a few times per week. a C'l'angiogram shows a type A aortic dissection. ra UI .D Between events, she engages in usual daily activities with l,l no limitations. She has no other pertinent history and takes Which of the following is the most appropriate treatment? la no medications. (D (A) Coronaryangiography Physical examination flndings, including vital signs, are normal. (B) Intravenous nitroprussicle .D aa Resting l2-lead ECG shows sinus rhythm and no (C) Open aortic repair abnormalities. (D) thoracic endovascular aortic repair Which of the following is the most appropriate diagnostic testing option? Item 63 :

t/r (D inciting factors, Iast 5 to 15 minutes, and are alleviated by Chest radiograph reveals a widened mediastinum, and rest or deep breathing. Ihey occur a few times per week. a C'l'angiogram shows a type A aortic dissection. ra UI .D Between events, she engages in usual daily activities with l,l no limitations. She has no other pertinent history and takes Which of the following is the most appropriate treatment? la no medications. (D (A) Coronaryangiography Physical examination flndings, including vital signs, are normal. (B) Intravenous nitroprussicle .D aa Resting l2-lead ECG shows sinus rhythm and no (C) Open aortic repair abnormalities. (D) thoracic endovascular aortic repair Which of the following is the most appropriate diagnostic testing option? Item 63 : (A) Exercise ECG A 45 year-old woman is evaluated for occasional palpita- (B) Implantable loop recorder tions. She also has hypertension. Medications are chlortha lidone and diltiazem. 1 (C) Mobile cardiac telemetry On physical examination, vital signs are normal. Car (D) 30-Day event monitor diac examination reveals an irregular rhythm. There is a . midsystolic click and late systolic murmur at the apex, radi ating to the back. There are no signs ofheart failure. tr Item 61 A 76 year old woman is evaluated in the en-rergency depart An ECG shows atrial flbrillation. with a ventricular rate of 80/min. \ menl lor acute onset substernal chest discomfort with asso A transthoracic echocardiogram shows severe poste- ciated dyspnea. The symptoms developed tl-ris morning after riorly directed mitral regurgitation, with a left ventricular her husband's unexpected death. She has hypertension ejection fraction of 557, and left ventricular end-systolic :

(A) Exercise ECG A 45 year-old woman is evaluated for occasional palpita- (B) Implantable loop recorder tions. She also has hypertension. Medications are chlortha lidone and diltiazem. 1 (C) Mobile cardiac telemetry On physical examination, vital signs are normal. Car (D) 30-Day event monitor diac examination reveals an irregular rhythm. There is a . midsystolic click and late systolic murmur at the apex, radi ating to the back. There are no signs ofheart failure. tr Item 61 A 76 year old woman is evaluated in the en-rergency depart An ECG shows atrial flbrillation. with a ventricular rate of 80/min. \ menl lor acute onset substernal chest discomfort with asso A transthoracic echocardiogram shows severe poste- ciated dyspnea. The symptoms developed tl-ris morning after riorly directed mitral regurgitation, with a left ventricular her husband's unexpected death. She has hypertension ejection fraction of 557, and left ventricular end-systolic : treated with chlorthalidone. dimension of 60 mm. There is severe anterior mitral valve ! Or.r physical examination, blood pressure is 140/70 mn.t prolapse; hemodynamic measurements indicate severe llg and pulse rate is 90/min. Oxygen saturation is 9B'1, with mitral regurgitation. the patient breathing ambicnt air. Other than an S.,, the carcliopulmonary examination is norma[. Which of the following is the most appropriate next step in Serum high sensitivity cardiac troponin level is ele management? .

treated with chlorthalidone. dimension of 60 mm. There is severe anterior mitral valve ! Or.r physical examination, blood pressure is 140/70 mn.t prolapse; hemodynamic measurements indicate severe llg and pulse rate is 90/min. Oxygen saturation is 9B'1, with mitral regurgitation. the patient breathing ambicnt air. Other than an S.,, the carcliopulmonary examination is norma[. Which of the following is the most appropriate next step in Serum high sensitivity cardiac troponin level is ele management? . vatecl (>99th percentile upper reference limit). An ECG demonstrates S'l' segment elevation in the (A) Cardiac magnetic resonance imaging I irnterior precordial leads. ancl echocardiogram shows (B) Surgical mitral valve repair preserved basal left ventricular flnction with apical and (C) Transcatheter mitral valve repair rnicl ventricular hypokinesis. The lefl ventricular ejection (D) Transesophagealechocardiography : fraction is 35',1,. Valve function and the ascending aorta appear normal. Coronary ar.rgiography shows normal cor ()nrry arteries. Item 64 tr l Which of the following is the most likely diagnosis? A 69 year old man is evaluated fbr a 1 week history of' redness at the site <,rf his pacenraker. Medical history is sig (A) Ascending aortic dissection nificrnt fbr diabetes mellitus and hypeftension. Medications (B) Coronary artery dissection are metfbrmin. atorvastatin, and Iisinopril. (C) Coron:rry artery embolism On physical examinatiorr, the patient is afebrile: other vital signs are normal. The pacemaker site is shown (l))'l'akotsubo cardiomyopathy (top of next page). The renrainder of the examination is unremarkable. Item 62 Laboratory studies, including lcukoc-y,te count. are within EX A 5,1 year old man is evaluated in the emergency depart normal limits. Three sets of blood cultures are ohtained. mcnt 2 hours after the orrset of acute, sharp, central chest pain that radiates to the back and has intensified over time. Which of the following is the most appropriate additional l le has hypertension. lle cluit smoking 2 years ago. Medica management? Iions are hydrochlorothiazidc and lisinopril. (A) Aspiration ofthedevice pocket On physical examination. blood pressure in the right (U) Pacemakerextraction ! rlrnl is 90,,56 mm Hg. blood pressure in the left arm is not obtainable, and pulse rate is l20r'min. He is confused and (C) 1'opical mupirocin ciiaphoretic. Cardiac examination reveals a summation gal (D) Clinical observation and rcassessment lop ancl a grade 3i 6 diastolic murmur at the right upper stenral border. Puln-ronary examination reveals crackles. q Itadial pulses are weakly prcsent on the right and absenl on Item 65 the left. l-ower extremity pulses are diminished. Skin is cool A 78-year old woman is evaluated 4 months after placement \ and mottled. of a drug-eluting stent for treatment of chronic stable angina : 140 i

Self-Assessment Test tt An echocardiogram shows a lelt ventricular ejection o, fraction of 5O%, increased left and right ventricular wall thickness, and abnormal left ventricular diastolic function. (, The estimated right ventricular systolic pressure is 64 mm Hg. E aa ra (l, Which ofthe following is the most appropriate management? a t (A) Cardiac resynchronizationtherapy (l, (ts) Cardiac transplanlation tl (C) Implantablecardioverter deflbrillator (D) Pulmonary vein isolation

(A) Cardiac resynchronizationtherapy (l, (ts) Cardiac transplanlation tl (C) Implantablecardioverter deflbrillator (D) Pulmonary vein isolation Item 67 A 46-year old man is evaluatecl fbr exertional chest pain that started 2 months ago. His pain is substernal and can tr also be provoked by stressful <lr emotional situations. The pain subsides in 2 to 3 minutes with rest. He has no other medical problems and takes no medications. Physical examination findings, including vital signs, are normal. ECG shows sinus rhythm with first degree atrioven tricular block. ITEM 64 Which ofthe following is the most appropriate management? pectoris. She is asymptomatic. She has hypertension, gas- (A) Coronary artery calcium scoring troesophageal reflux disease, and a history ofseveral colonic (B) Exercise ECG angiodysplasias treated with electrocoagulation 8 months (C) Exerciseechocardiography ago. Medications are pravastatin, aspirin, clopidogrel, metop- rolol, hydrochlorothiazide, ferrous sulfate, and omeprazole. (D) 48 Hour ambulatory ECG On physical examination, blood pressure isl32l72mm Hg, pulse rate is 78/min, and respiration rate is 2Olmin. BMI is 17. Scattered ecchymoses are evident over both lower Item 68 extremities. A 28-year-old woman is seen for pregnancy planning. She Results of laboratory studies show a hematocrit of 34%. underwent mitral valve replacement with a mechanical prosthesis 4 years ago for congenital mitral valve stenosis. Which of the following is the most appropriate initial She is asymptomatic. Medications are warfarin, 4 mg/d, and management? low-dose aspirin. Her INR measurements have been within the therapeutic range for the past 18 months, including her (A) Assess platelet reactivity most recent INR measurement of 3.0. (B) Discontinueaspirin Other than a mechanical-sounding Sr, vital signs and (C) Discontinue clopidogrel all physical examination flndings are normal. (D) Discontinueomeprazole Echocardiography shows a normally functioning mitral valve prosthesis and normal left ventricular function and estimated pulmonary artery pressure.

Item 67 A 46-year old man is evaluatecl fbr exertional chest pain that started 2 months ago. His pain is substernal and can tr also be provoked by stressful <lr emotional situations. The pain subsides in 2 to 3 minutes with rest. He has no other medical problems and takes no medications. Physical examination findings, including vital signs, are normal. ECG shows sinus rhythm with first degree atrioven tricular block. ITEM 64 Which ofthe following is the most appropriate management? pectoris. She is asymptomatic. She has hypertension, gas- (A) Coronary artery calcium scoring troesophageal reflux disease, and a history ofseveral colonic (B) Exercise ECG angiodysplasias treated with electrocoagulation 8 months (C) Exerciseechocardiography ago. Medications are pravastatin, aspirin, clopidogrel, metop- rolol, hydrochlorothiazide, ferrous sulfate, and omeprazole. (D) 48 Hour ambulatory ECG On physical examination, blood pressure isl32l72mm Hg, pulse rate is 78/min, and respiration rate is 2Olmin. BMI is 17. Scattered ecchymoses are evident over both lower Item 68 extremities. A 28-year-old woman is seen for pregnancy planning. She Results of laboratory studies show a hematocrit of 34%. underwent mitral valve replacement with a mechanical prosthesis 4 years ago for congenital mitral valve stenosis. Which of the following is the most appropriate initial She is asymptomatic. Medications are warfarin, 4 mg/d, and management? low-dose aspirin. Her INR measurements have been within the therapeutic range for the past 18 months, including her (A) Assess platelet reactivity most recent INR measurement of 3.0. (B) Discontinueaspirin Other than a mechanical-sounding Sr, vital signs and (C) Discontinue clopidogrel all physical examination flndings are normal. (D) Discontinueomeprazole Echocardiography shows a normally functioning mitral valve prosthesis and normal left ventricular function and estimated pulmonary artery pressure. tr Item 66 A 65-year-old man is evaluated in the hospital for progres The patient would like to attempt pregnancy as soon as possible. During this time, aspirin will be continued.

tr Item 66 A 65-year-old man is evaluated in the hospital for progres The patient would like to attempt pregnancy as soon as possible. During this time, aspirin will be continued. sive dyspnea with light exertion. He was diagnosed with Which of the following is the most appropriate restrictive cardiomyopathy 2 years ago and atrial flbrillation anticoagulation stratery during the first trimester? 18 months ago. Attempts at pharmacologic rhythm control have been unsuccessful. Medications are apixaban, spirono- (A) Stop warfarin and start bivalirudin lactone, torsemide, and potassium chloride. (B) Stop warfarin and start dabigatran On physical examination, blood pressure is 106/68 mm (C) Stop warfarin and start subcutaneous dose-adjusted Hg, pulse rate is 86/min and irregularly irregular, and oxy- unfractionated heparin gen saturation is 94% with the patient breathing ambient air. Central venous pressure is elevated. Bibasilar crackles (D) Continue warfarin are present. Hepatomegaly is noted. There is bilateral pitting edema to the knees. ECG shows atrial fibrillation with a ventricular rate of Item 69 86/min, right bundle branch block, and QRS duration of A 72-year-old man is evaluated in the office following a 136 ms. non-ST-elevation myocardial infarction. He underwent 141

Self-Assessment Test vr .D percutaneous coronary intervention and is currently lntravenous furosemide and bilevel positive airway asymptomatic. Medications are low-dose aspirin, ticagrelor, pressure are initiated. UI UI .D lisinopril, metoprolol, and atorvastatin. l^ (a On physical examination, blood pressure is 140/72 mm Which of the following is the most appropriate additional Hg; other vital signs are normal. Femoral bruits are pres treatment? .D ent bilaterally. Femoral and pedal pulses are diminished (A) Bisoprolol bilaterally. .D (B) Diltiazem (,t Ankle-brachial index testing: (C) Enalapril Right systolic brachial pressure 140 mm Hg (D) Ivabradine Left systolic brachial pressure 95 mm Hg Right dorsalis pedis pressure 112 mm Hg Left dorsalis pedis pressure 120 mm Hg Item 71 \ Right posterior tibialis pressure 100 mm Hg A 25-year old man is evaluated fbr recurrent syncope. The Left posterior tibialis pressure 116 mm Hg syncopal episodes are abrupt and without prodrome and I have occurred several times during the past year. He reports Which of the following is the most appropriate test to no chest pain or exertional symptoms' He has no other perform next? pertinent personal history. His father died in his sleep at age (A) Exercise ankle brachial index testing 45 years. He takes no medications. (B) Lower extremity CT angiography On physical examination, vital signs are normal. There is no heart murmur. The remainder of the examination is (C) Toe-brachial index testing unremarkable. (D) No additional testing Laboratory studies, including a comprehensive meta bolic panel, are within normal limits. ECG is shown. Echocardiogram is normal.

vr .D percutaneous coronary intervention and is currently lntravenous furosemide and bilevel positive airway asymptomatic. Medications are low-dose aspirin, ticagrelor, pressure are initiated. UI UI .D lisinopril, metoprolol, and atorvastatin. l^ (a On physical examination, blood pressure is 140/72 mm Which of the following is the most appropriate additional Hg; other vital signs are normal. Femoral bruits are pres treatment? .D ent bilaterally. Femoral and pedal pulses are diminished (A) Bisoprolol bilaterally. .D (B) Diltiazem (,t Ankle-brachial index testing: (C) Enalapril Right systolic brachial pressure 140 mm Hg (D) Ivabradine Left systolic brachial pressure 95 mm Hg Right dorsalis pedis pressure 112 mm Hg Left dorsalis pedis pressure 120 mm Hg Item 71 \ Right posterior tibialis pressure 100 mm Hg A 25-year old man is evaluated fbr recurrent syncope. The Left posterior tibialis pressure 116 mm Hg syncopal episodes are abrupt and without prodrome and I have occurred several times during the past year. He reports Which of the following is the most appropriate test to no chest pain or exertional symptoms' He has no other perform next? pertinent personal history. His father died in his sleep at age (A) Exercise ankle brachial index testing 45 years. He takes no medications. (B) Lower extremity CT angiography On physical examination, vital signs are normal. There is no heart murmur. The remainder of the examination is (C) Toe-brachial index testing unremarkable. (D) No additional testing Laboratory studies, including a comprehensive meta bolic panel, are within normal limits. ECG is shown. Echocardiogram is normal. tr Item 70 A 27- year-old woman is hospitalized for a l-day history of Which of the following is the most likely diagnosis? orthopnea and paroxysmal nocturnal dyspnea. She deliv- (A) Brugada syndrome ered a healthy baby boy 6 days ago. She is breastfeeding. On physical examination, blood pressure is 134/78 mm (B) Coronary artery disease :

tr Item 70 A 27- year-old woman is hospitalized for a l-day history of Which of the following is the most likely diagnosis? orthopnea and paroxysmal nocturnal dyspnea. She deliv- (A) Brugada syndrome ered a healthy baby boy 6 days ago. She is breastfeeding. On physical examination, blood pressure is 134/78 mm (B) Coronary artery disease : Hg, pulse rate is 98/min, respiration rate is 26lmin. and (C) Long QT syndrome oxygen saturation is 94'7, with the patient breathing ambi (D) Vasovagal syncope ent air. There is jugular venous distention and an Sr. Crack- , les are heard about halfway up the lungs. There is lower extremity edema to the knees. Laboratory studies show an elevated B-type natriuretic Item 72 A 30-year-old man is hospitalized for a 3 day history of pro tr i peptide level, a normal high-sensitivity troponin level gressive fatigue, fever, and shortness ofbreath. He under (<99th percentile upper reference limit), and a serum cre- went surgical aortic valve replacement 3 years ago. He also atinine level of 1.2 mg/dl (106.1 pmol/L). has end-stage kidney disease. fbr which he receives hemo Chest radiograph shows pulmonary edema. Echocar dialysis. Medications are lisinopril, sevelamer, and warf'arin. diogram shows an ejection fraction of20% and di{Iuse hypo On physical examination, blood pressure is 145/34 mm kinesis. I'tg and pulse rate is l20i min. Cardiac examination reveals '{- --1- ''

Hg, pulse rate is 98/min, respiration rate is 26lmin. and (C) Long QT syndrome oxygen saturation is 94'7, with the patient breathing ambi (D) Vasovagal syncope ent air. There is jugular venous distention and an Sr. Crack- , les are heard about halfway up the lungs. There is lower extremity edema to the knees. Laboratory studies show an elevated B-type natriuretic Item 72 A 30-year-old man is hospitalized for a 3 day history of pro tr i peptide level, a normal high-sensitivity troponin level gressive fatigue, fever, and shortness ofbreath. He under (<99th percentile upper reference limit), and a serum cre- went surgical aortic valve replacement 3 years ago. He also atinine level of 1.2 mg/dl (106.1 pmol/L). has end-stage kidney disease. fbr which he receives hemo Chest radiograph shows pulmonary edema. Echocar dialysis. Medications are lisinopril, sevelamer, and warf'arin. diogram shows an ejection fraction of20% and di{Iuse hypo On physical examination, blood pressure is 145/34 mm kinesis. I'tg and pulse rate is l20i min. Cardiac examination reveals '{- --1- '' I --l- -v +- -"i tv n ;*r l : - ITEM 71 142

Self-Assessment Test r,D tr CONT. bounding pulses and a loud decrescendo diastolic murmur at the left sternal border. Crackles are heard at the lung bzrses. An tiCG shows prolonged first degree atrioventricu Today, the hemoglobin Ievel is 74.8 gldL (148 g/L), and iron studies are compatible with iron deficiency. F6' E o, lar btock. A chest radiograph reveals pulmonary edema. E Which of the following is the most appropriate initial Ut Ul A transthoracic echocardiogrant reveals a left ventricular management? o t^ ejection fiaction of 60'1, with nornral left ventricular dinren UI (A) Hysterectomy sions and a 1.S-cm vegetation on the aclrtic valve biopros thesis associated with severe aortic regurgitation. (B) Oral iron therapy so Multiple blood cultures are obtained, irnd empiric (C) Phlebotomy vt intravenous antibiotic therapy is initiated. (D) Supplemental oxygen therapy

tr CONT. bounding pulses and a loud decrescendo diastolic murmur at the left sternal border. Crackles are heard at the lung bzrses. An tiCG shows prolonged first degree atrioventricu Today, the hemoglobin Ievel is 74.8 gldL (148 g/L), and iron studies are compatible with iron deficiency. F6' E o, lar btock. A chest radiograph reveals pulmonary edema. E Which of the following is the most appropriate initial Ut Ul A transthoracic echocardiogrant reveals a left ventricular management? o t^ ejection fiaction of 60'1, with nornral left ventricular dinren UI (A) Hysterectomy sions and a 1.S-cm vegetation on the aclrtic valve biopros thesis associated with severe aortic regurgitation. (B) Oral iron therapy so Multiple blood cultures are obtained, irnd empiric (C) Phlebotomy vt intravenous antibiotic therapy is initiated. (D) Supplemental oxygen therapy Which ofthe following is the most appropriate management? (A) Cardiac cetheterizxtion (B) Early surgical aortic valve replacement Item 74 A 58 year old man is evaluated in the emergency depart- tr ment 30 minutes after onset of severe and persistent chest (C) Placement of a temporary pacemaker pain at rest associated with diaphoresis and nausea. His (D) No change in therapy medical diagnoses include hypertension and hyperlipid emia treated with amlodipine and atorvastatin. An ECG is shown. Item 73 On physical examination, blclod pressure is 159/84 mm A 44 year-old woman is evaluated for a 6 month history of Hg, pulse rate is 50/min, respiration rate is 181min, and oxy progressive exertional dyspnea and fatigue coincident with gen saturation is 94'l, with the patient breathing ambient the onset of hear,y menstrual periods. Before the onset of air. BMI is 25. All other physical examination findings are symptoms, her hemoglobin level was 17.9 gldL (179 glL). unremarkable. Medical history is significant for a large patent ductus arte- The nearest percutaneous coronary intervention (PCI) riosus and resultant Eisenmenger syndrome. Her only med- center is located at least 140 minutes awav. ication is bosentan for pulmonary arterial hypertension. On physical examination, blood pressure is 100/65 mm Which of the following is the most appropriate Hg; the remaining vital signs are normal. Oxygen saturation management? with the patient breathing ambient air is 92'2, in the upper (A) CT angiography extremities and B2'7, in the lower extremities. There is jugu (B) Thrombolysis and admission to a telemetry bed lar venous distention with a prontinent o wave, and a prom inent left parasternal impulse is noted. S, is loud. Clubbing (C) Thrombolysis and transfer to a PCI center of the toes and central cyanosis are present. (D) Transfer to a PCI center for primary PCI

Which ofthe following is the most appropriate management? (A) Cardiac cetheterizxtion (B) Early surgical aortic valve replacement Item 74 A 58 year old man is evaluated in the emergency depart- tr ment 30 minutes after onset of severe and persistent chest (C) Placement of a temporary pacemaker pain at rest associated with diaphoresis and nausea. His (D) No change in therapy medical diagnoses include hypertension and hyperlipid emia treated with amlodipine and atorvastatin. An ECG is shown. Item 73 On physical examination, blclod pressure is 159/84 mm A 44 year-old woman is evaluated for a 6 month history of Hg, pulse rate is 50/min, respiration rate is 181min, and oxy progressive exertional dyspnea and fatigue coincident with gen saturation is 94'l, with the patient breathing ambient the onset of hear,y menstrual periods. Before the onset of air. BMI is 25. All other physical examination findings are symptoms, her hemoglobin level was 17.9 gldL (179 glL). unremarkable. Medical history is significant for a large patent ductus arte- The nearest percutaneous coronary intervention (PCI) riosus and resultant Eisenmenger syndrome. Her only med- center is located at least 140 minutes awav. ication is bosentan for pulmonary arterial hypertension. On physical examination, blood pressure is 100/65 mm Which of the following is the most appropriate Hg; the remaining vital signs are normal. Oxygen saturation management? with the patient breathing ambient air is 92'2, in the upper (A) CT angiography extremities and B2'7, in the lower extremities. There is jugu (B) Thrombolysis and admission to a telemetry bed lar venous distention with a prontinent o wave, and a prom inent left parasternal impulse is noted. S, is loud. Clubbing (C) Thrombolysis and transfer to a PCI center of the toes and central cyanosis are present. (D) Transfer to a PCI center for primary PCI $L 1,.

Which ofthe following is the most appropriate management? (A) Cardiac cetheterizxtion (B) Early surgical aortic valve replacement Item 74 A 58 year old man is evaluated in the emergency depart- tr ment 30 minutes after onset of severe and persistent chest (C) Placement of a temporary pacemaker pain at rest associated with diaphoresis and nausea. His (D) No change in therapy medical diagnoses include hypertension and hyperlipid emia treated with amlodipine and atorvastatin. An ECG is shown. Item 73 On physical examination, blclod pressure is 159/84 mm A 44 year-old woman is evaluated for a 6 month history of Hg, pulse rate is 50/min, respiration rate is 181min, and oxy progressive exertional dyspnea and fatigue coincident with gen saturation is 94'l, with the patient breathing ambient the onset of hear,y menstrual periods. Before the onset of air. BMI is 25. All other physical examination findings are symptoms, her hemoglobin level was 17.9 gldL (179 glL). unremarkable. Medical history is significant for a large patent ductus arte- The nearest percutaneous coronary intervention (PCI) riosus and resultant Eisenmenger syndrome. Her only med- center is located at least 140 minutes awav. ication is bosentan for pulmonary arterial hypertension. On physical examination, blood pressure is 100/65 mm Which of the following is the most appropriate Hg; the remaining vital signs are normal. Oxygen saturation management? with the patient breathing ambient air is 92'2, in the upper (A) CT angiography extremities and B2'7, in the lower extremities. There is jugu (B) Thrombolysis and admission to a telemetry bed lar venous distention with a prontinent o wave, and a prom inent left parasternal impulse is noted. S, is loud. Clubbing (C) Thrombolysis and transfer to a PCI center of the toes and central cyanosis are present. (D) Transfer to a PCI center for primary PCI $L 1,. r1? 1.6 m

Which ofthe following is the most appropriate management? (A) Cardiac cetheterizxtion (B) Early surgical aortic valve replacement Item 74 A 58 year old man is evaluated in the emergency depart- tr ment 30 minutes after onset of severe and persistent chest (C) Placement of a temporary pacemaker pain at rest associated with diaphoresis and nausea. His (D) No change in therapy medical diagnoses include hypertension and hyperlipid emia treated with amlodipine and atorvastatin. An ECG is shown. Item 73 On physical examination, blclod pressure is 159/84 mm A 44 year-old woman is evaluated for a 6 month history of Hg, pulse rate is 50/min, respiration rate is 181min, and oxy progressive exertional dyspnea and fatigue coincident with gen saturation is 94'l, with the patient breathing ambient the onset of hear,y menstrual periods. Before the onset of air. BMI is 25. All other physical examination findings are symptoms, her hemoglobin level was 17.9 gldL (179 glL). unremarkable. Medical history is significant for a large patent ductus arte- The nearest percutaneous coronary intervention (PCI) riosus and resultant Eisenmenger syndrome. Her only med- center is located at least 140 minutes awav. ication is bosentan for pulmonary arterial hypertension. On physical examination, blood pressure is 100/65 mm Which of the following is the most appropriate Hg; the remaining vital signs are normal. Oxygen saturation management? with the patient breathing ambient air is 92'2, in the upper (A) CT angiography extremities and B2'7, in the lower extremities. There is jugu (B) Thrombolysis and admission to a telemetry bed lar venous distention with a prontinent o wave, and a prom inent left parasternal impulse is noted. S, is loud. Clubbing (C) Thrombolysis and transfer to a PCI center of the toes and central cyanosis are present. (D) Transfer to a PCI center for primary PCI $L 1,. r1? 1.6 m il

Which ofthe following is the most appropriate management? (A) Cardiac cetheterizxtion (B) Early surgical aortic valve replacement Item 74 A 58 year old man is evaluated in the emergency depart- tr ment 30 minutes after onset of severe and persistent chest (C) Placement of a temporary pacemaker pain at rest associated with diaphoresis and nausea. His (D) No change in therapy medical diagnoses include hypertension and hyperlipid emia treated with amlodipine and atorvastatin. An ECG is shown. Item 73 On physical examination, blclod pressure is 159/84 mm A 44 year-old woman is evaluated for a 6 month history of Hg, pulse rate is 50/min, respiration rate is 181min, and oxy progressive exertional dyspnea and fatigue coincident with gen saturation is 94'l, with the patient breathing ambient the onset of hear,y menstrual periods. Before the onset of air. BMI is 25. All other physical examination findings are symptoms, her hemoglobin level was 17.9 gldL (179 glL). unremarkable. Medical history is significant for a large patent ductus arte- The nearest percutaneous coronary intervention (PCI) riosus and resultant Eisenmenger syndrome. Her only med- center is located at least 140 minutes awav. ication is bosentan for pulmonary arterial hypertension. On physical examination, blood pressure is 100/65 mm Which of the following is the most appropriate Hg; the remaining vital signs are normal. Oxygen saturation management? with the patient breathing ambient air is 92'2, in the upper (A) CT angiography extremities and B2'7, in the lower extremities. There is jugu (B) Thrombolysis and admission to a telemetry bed lar venous distention with a prontinent o wave, and a prom inent left parasternal impulse is noted. S, is loud. Clubbing (C) Thrombolysis and transfer to a PCI center of the toes and central cyanosis are present. (D) Transfer to a PCI center for primary PCI $L 1,. r1? 1.6 m il vt ITEM 74

Which ofthe following is the most appropriate management? (A) Cardiac cetheterizxtion (B) Early surgical aortic valve replacement Item 74 A 58 year old man is evaluated in the emergency depart- tr ment 30 minutes after onset of severe and persistent chest (C) Placement of a temporary pacemaker pain at rest associated with diaphoresis and nausea. His (D) No change in therapy medical diagnoses include hypertension and hyperlipid emia treated with amlodipine and atorvastatin. An ECG is shown. Item 73 On physical examination, blclod pressure is 159/84 mm A 44 year-old woman is evaluated for a 6 month history of Hg, pulse rate is 50/min, respiration rate is 181min, and oxy progressive exertional dyspnea and fatigue coincident with gen saturation is 94'l, with the patient breathing ambient the onset of hear,y menstrual periods. Before the onset of air. BMI is 25. All other physical examination findings are symptoms, her hemoglobin level was 17.9 gldL (179 glL). unremarkable. Medical history is significant for a large patent ductus arte- The nearest percutaneous coronary intervention (PCI) riosus and resultant Eisenmenger syndrome. Her only med- center is located at least 140 minutes awav. ication is bosentan for pulmonary arterial hypertension. On physical examination, blood pressure is 100/65 mm Which of the following is the most appropriate Hg; the remaining vital signs are normal. Oxygen saturation management? with the patient breathing ambient air is 92'2, in the upper (A) CT angiography extremities and B2'7, in the lower extremities. There is jugu (B) Thrombolysis and admission to a telemetry bed lar venous distention with a prontinent o wave, and a prom inent left parasternal impulse is noted. S, is loud. Clubbing (C) Thrombolysis and transfer to a PCI center of the toes and central cyanosis are present. (D) Transfer to a PCI center for primary PCI $L 1,. r1? 1.6 m il vt ITEM 74 143

Self-Assessment Test ull .D Item 75 Which of the following is the most appropriate treatment? lrt An 18-year old man is evaluated before participating on his (A) Cardiacresynchronizationtherapy defibrillator rrt .D ut college basketball team. He has no history of hypertension (B) Implantable cardioverter-deflbrillator UI or other pertinent medical history. He has no history of (C) Implantable pulmonary artery pressure sensor palpitations, chest pain, or unusual dyspnea, and there is no .D (D) Wearablecardioverter deflbrillator family history of sudden cardiac death or cardiomyopathy. { (D On physical examination, blood pressure is 110/70 mm UI Hg and pulse rate is 52/min. BMI is 22. No murmur is heard.

ull .D Item 75 Which of the following is the most appropriate treatment? lrt An 18-year old man is evaluated before participating on his (A) Cardiacresynchronizationtherapy defibrillator rrt .D ut college basketball team. He has no history of hypertension (B) Implantable cardioverter-deflbrillator UI or other pertinent medical history. He has no history of (C) Implantable pulmonary artery pressure sensor palpitations, chest pain, or unusual dyspnea, and there is no .D (D) Wearablecardioverter deflbrillator family history of sudden cardiac death or cardiomyopathy. { (D On physical examination, blood pressure is 110/70 mm UI Hg and pulse rate is 52/min. BMI is 22. No murmur is heard. left ECG shows sinus bradycardia, with voltage criteria for ventricular (LV) hypertrophy. The corrected QT interval Item 78 A 72 year old man is evaluated in the emergency depafi tx is 400 ms. Early repolarization is noted. ment fbr sudden-onset anterior chest pain radiating to his An echocardiogram shows a mildly dilated LV cavity. back. I te has no history of heart murmur or aortic disease. The ejection fraction is greater than 55% without regional I{e has hypertension treated with chlorthalidone ancl val abnormality. Symmetric LV hypertrophy is noted, with LV sartan. wall thickness of 12 mm. LV diastolic fllling, left atrial size, On physical examination, bloocl pressure is 182/54 mm and valvular structure and function are normal. IIg in the right arm and 12.5i 63 mm Hg in the left arm. lhere is a grade 2/6 decrescendo diastolic murmur heard at the Which of the following is the most likely diagnosis? left sternal border. Central venous pressure is elevated. and there are crackles at the lung bases. (A) Athlete heart Chest radiograph shows pulmonary edema and a rvid (B) Fabrydisease ened mediastinum. A CT angiogram short's an ascending (C) Hypertensive heart disease aortic dissection extending into the aortic arch. An echo- (D) Nonobstructive hypertrophic cardiomyopathy cardiogram sl.rows a left ventricular ejection fraction of 55'X, and moderate aortic regurgitation.

left ECG shows sinus bradycardia, with voltage criteria for ventricular (LV) hypertrophy. The corrected QT interval Item 78 A 72 year old man is evaluated in the emergency depafi tx is 400 ms. Early repolarization is noted. ment fbr sudden-onset anterior chest pain radiating to his An echocardiogram shows a mildly dilated LV cavity. back. I te has no history of heart murmur or aortic disease. The ejection fraction is greater than 55% without regional I{e has hypertension treated with chlorthalidone ancl val abnormality. Symmetric LV hypertrophy is noted, with LV sartan. wall thickness of 12 mm. LV diastolic fllling, left atrial size, On physical examination, bloocl pressure is 182/54 mm and valvular structure and function are normal. IIg in the right arm and 12.5i 63 mm Hg in the left arm. lhere is a grade 2/6 decrescendo diastolic murmur heard at the Which of the following is the most likely diagnosis? left sternal border. Central venous pressure is elevated. and there are crackles at the lung bases. (A) Athlete heart Chest radiograph shows pulmonary edema and a rvid (B) Fabrydisease ened mediastinum. A CT angiogram short's an ascending (C) Hypertensive heart disease aortic dissection extending into the aortic arch. An echo- (D) Nonobstructive hypertrophic cardiomyopathy cardiogram sl.rows a left ventricular ejection fraction of 55'X, and moderate aortic regurgitation. Item 76 Which of the following is the most appropriate A 42-year old woman is evaluated for a 3-month history of management? exertional dyspnea and a burning sensation in her throat. She had Hodgkin lymphoma at age 22 years treated with (A) Cardiac rnitgnetic res()nunce intlging chemotherapy and mantle irradiation. She has no history (B) Emergent surgery of hypertension, hyperlipidemia, or diabetes mellitus and (C) h-rtra aortic balloon counterpulsation has never smoked. (D) Transesophageal echocarcliography On physical examination, vital signs are normal. No jugular venous distention is seen. Heart sounds are normal. No murmur or early diastolic sound is heard. There is no Item 79 peripheral edema. A chest radiograph and 12 lead ECG are normal. A 68-year-old man is evaluated during a routine follow up visit. Medical history is signiflcant for type 2 diabetes melli- Which of the following is the most likely diagnosis? tus, hyperlipidemia, hlpertension, and aortofemoral bypass surgery 2 years ago. Previous evaluation documented a left (A) Aortic stenosis ventricular ejection fraction of50% and stage G3bA2 chronic (B) Constrictivepericarditis kidney disease. Medications are metformin, atenolol, lisin (C) Coronary artery disease opril, amlodipine, aspirin, rivaroxaban, and atorvastatin. (D) Mitral stenosis On physical examination, vital signs are normal. BMI is 30. An aortofemoral bypass surgical scar is present. Pulses (E) Restrictivecardiomyopathy are present and moderately strong in the lower extremities. The most recent hemoglobin A,. level is7.l%. Item 77 A 63-year old man is evaluated during a follow up visit for Which of the following is the most appropriate additional a 6 month history of heart failure. He currently has New treatment? York Heart Association functional class III symptoms. His (A) Clopidogrel only hospitalization was at the time of diagnosis. Medica- (B) Liraglutide tions are valsartan sacubitril, carvedilol, furosemide, and (C) Niacin spironolactone. On physical examination, blood pressure is 110/76 mm (D) Pramlintide Hg and pulse rate is 64lmin. The remainder of the examina tion is unremarkable. Laboratory studies are within normal limits. ECG demonstrates left bundle branch block with a Item 8O A 48-year old woman is evaluated in the hospital for trirn- tr QRS duration of 130 ms. Since beginning guideline-directed sient left facial droop and right sided weakness, which medical therapy, his ejection fraction has increased from lasted 15 minutes and completely resolved. She also has a 15"/,'to25%. 1-month history of recurrent f'evers and night sweats. She

Item 76 Which of the following is the most appropriate A 42-year old woman is evaluated for a 3-month history of management? exertional dyspnea and a burning sensation in her throat. She had Hodgkin lymphoma at age 22 years treated with (A) Cardiac rnitgnetic res()nunce intlging chemotherapy and mantle irradiation. She has no history (B) Emergent surgery of hypertension, hyperlipidemia, or diabetes mellitus and (C) h-rtra aortic balloon counterpulsation has never smoked. (D) Transesophageal echocarcliography On physical examination, vital signs are normal. No jugular venous distention is seen. Heart sounds are normal. No murmur or early diastolic sound is heard. There is no Item 79 peripheral edema. A chest radiograph and 12 lead ECG are normal. A 68-year-old man is evaluated during a routine follow up visit. Medical history is signiflcant for type 2 diabetes melli- Which of the following is the most likely diagnosis? tus, hyperlipidemia, hlpertension, and aortofemoral bypass surgery 2 years ago. Previous evaluation documented a left (A) Aortic stenosis ventricular ejection fraction of50% and stage G3bA2 chronic (B) Constrictivepericarditis kidney disease. Medications are metformin, atenolol, lisin (C) Coronary artery disease opril, amlodipine, aspirin, rivaroxaban, and atorvastatin. (D) Mitral stenosis On physical examination, vital signs are normal. BMI is 30. An aortofemoral bypass surgical scar is present. Pulses (E) Restrictivecardiomyopathy are present and moderately strong in the lower extremities. The most recent hemoglobin A,. level is7.l%. Item 77 A 63-year old man is evaluated during a follow up visit for Which of the following is the most appropriate additional a 6 month history of heart failure. He currently has New treatment? York Heart Association functional class III symptoms. His (A) Clopidogrel only hospitalization was at the time of diagnosis. Medica- (B) Liraglutide tions are valsartan sacubitril, carvedilol, furosemide, and (C) Niacin spironolactone. On physical examination, blood pressure is 110/76 mm (D) Pramlintide Hg and pulse rate is 64lmin. The remainder of the examina tion is unremarkable. Laboratory studies are within normal limits. ECG demonstrates left bundle branch block with a Item 8O A 48-year old woman is evaluated in the hospital for trirn- tr QRS duration of 130 ms. Since beginning guideline-directed sient left facial droop and right sided weakness, which medical therapy, his ejection fraction has increased from lasted 15 minutes and completely resolved. She also has a 15"/,'to25%. 1-month history of recurrent f'evers and night sweats. She 144

Self-Assessment Test Ut f_tll reports lack ot appetite and unintentional weight loss of Which of the following is the most appropriate treatment? Fo, lll z s kg (5 lb). She has no orher symptoms or medical prob, c0Nl 1.-r and has not undergone a rec.ent medical proceclure. (A) Atropine o She takes no medicatior.rs. (ts) Intravenous unfractionated hcparin tr Ut Orr physical examinaticln. vital signs are nonnal. Car, ((l) Temporary pacing U! g, diac examination reveals a normal S, and Sr, with a so{t early UI (D) Urgentdual chamberpacemakcr ra diastolic sound heard best at the apex. ECG dcmonstrates normal sinus rhythm. o tt CT of'the head with and without contrast is normal. Item 82 Echocarcliogram (shown) denlonstrates normal chamber A 78 year-old woman is evaluated for 6 weeks of exertional size and ventricular function (LV = left ventricler RA = right dyspnea. She has hypertension and paroxysmal atrial flbril irtrium; RV = right ventricle). lation. Medications are apixaban, enalapril, and chlortha- lidone. On physical examination, blood pressure is 148/90 mm Hg; other vital signs are normal. BMI is 38. Central venous pressure is normal, and lungs are clear. An Sr, but no mur mur, is noted. B-type natriuretic peptide level is 211 pg/ml (2ttnglL). An ECG demonstrates sinus rhythm and left ventric ular hypertrophy. An echocardiogram shows an ejection fraction of55% and increased left ventricular wall thickness. The calculated cardiac index is 2.9 L/min/m2. There is no rest or dynamic outflow tract obstruction. The estimated right ventricular systolic pressure is 40 mm Hg. The left atrium is enlarged.

Ut f_tll reports lack ot appetite and unintentional weight loss of Which of the following is the most appropriate treatment? Fo, lll z s kg (5 lb). She has no orher symptoms or medical prob, c0Nl 1.-r and has not undergone a rec.ent medical proceclure. (A) Atropine o She takes no medicatior.rs. (ts) Intravenous unfractionated hcparin tr Ut Orr physical examinaticln. vital signs are nonnal. Car, ((l) Temporary pacing U! g, diac examination reveals a normal S, and Sr, with a so{t early UI (D) Urgentdual chamberpacemakcr ra diastolic sound heard best at the apex. ECG dcmonstrates normal sinus rhythm. o tt CT of'the head with and without contrast is normal. Item 82 Echocarcliogram (shown) denlonstrates normal chamber A 78 year-old woman is evaluated for 6 weeks of exertional size and ventricular function (LV = left ventricler RA = right dyspnea. She has hypertension and paroxysmal atrial flbril irtrium; RV = right ventricle). lation. Medications are apixaban, enalapril, and chlortha- lidone. On physical examination, blood pressure is 148/90 mm Hg; other vital signs are normal. BMI is 38. Central venous pressure is normal, and lungs are clear. An Sr, but no mur mur, is noted. B-type natriuretic peptide level is 211 pg/ml (2ttnglL). An ECG demonstrates sinus rhythm and left ventric ular hypertrophy. An echocardiogram shows an ejection fraction of55% and increased left ventricular wall thickness. The calculated cardiac index is 2.9 L/min/m2. There is no rest or dynamic outflow tract obstruction. The estimated right ventricular systolic pressure is 40 mm Hg. The left atrium is enlarged. Which of the following is the most likely diagnosis? (A) Heart failure with preserved ejection fraction (B) High output heart failure (C) Hypertrophic obstructive cardiomyopathy (D) Noncardiac dyspnea

Which of the following is the most likely diagnosis? (A) Heart failure with preserved ejection fraction (B) High output heart failure (C) Hypertrophic obstructive cardiomyopathy (D) Noncardiac dyspnea Which of the following is the most appropriate Item 83 management? A 76 year-old woman is evaluated during a wellness visit. (A) Administer a direct oral anticr,ragulant She reports that she fatigues easily, and her husband notes (B) Administerintravenousthrombolytic therapy that she snores loudly. Medical history is signiflcant for (C) Obtain blood cultures and begin empiric antibiotics hypertension. Her only medication is metoprolol. (D) Urgcnt surgicrl excision On physical examination, pulse rate is 75lmin and irregular; other vital signs are normal. Cardiac examination reveals irregular heart sounds with no murmurs or gallops. No signs of heart failure are present. tr Item 81 A 53 year old woman is evaluated in the coronary care An ECG shows atrial flbrillation at 75lmin without ischemic changes. l unit. She underwent successtirl primary percutaneous coronary intcrvention with drug-eluting stent placement Which of the following is the most appropriate in the mid right coronary artery fbr an inferior S'l' elevation management? myocardial infarction. ln the catheterization laboratory. she had several episodes of symptornatic 2:1 atrioventric (A) Add aspirin ular block with sinus bradycardia. After returning to the (B) Emergent cardioversion coronary care unit, she has symptomatic intermittent 2:l (C) Increase metoprolol dosage atrioventricular block and several episodes of c<lmplete (D) Initiate oral anticoagulation heart block with a narrou, complex escape rhythrn (heart rate at 58i min). Meclications are atorvastalin. aspirin. and (E) Reassurance clopidogrel. On physical examination. blood pressure is 1lBiB2 mm FIg. pulse rate is 681min. respiration rate is lB/min. Item 84 and oxygen saturation is 96'7, with the patient breath A 55 year old man is evaluated for a 6 week history of ing ambient air. Cardiac examination reveals a regularly cough and worsening exertional dyspnea and orthopnea. irregular rhythm. The remainder ol the examination is He has heart failure, for which he has received guideline- normal. directed medical therapy for 4 months.

Which of the following is the most appropriate Item 83 management? A 76 year-old woman is evaluated during a wellness visit. (A) Administer a direct oral anticr,ragulant She reports that she fatigues easily, and her husband notes (B) Administerintravenousthrombolytic therapy that she snores loudly. Medical history is signiflcant for (C) Obtain blood cultures and begin empiric antibiotics hypertension. Her only medication is metoprolol. (D) Urgcnt surgicrl excision On physical examination, pulse rate is 75lmin and irregular; other vital signs are normal. Cardiac examination reveals irregular heart sounds with no murmurs or gallops. No signs of heart failure are present. tr Item 81 A 53 year old woman is evaluated in the coronary care An ECG shows atrial flbrillation at 75lmin without ischemic changes. l unit. She underwent successtirl primary percutaneous coronary intcrvention with drug-eluting stent placement Which of the following is the most appropriate in the mid right coronary artery fbr an inferior S'l' elevation management? myocardial infarction. ln the catheterization laboratory. she had several episodes of symptornatic 2:1 atrioventric (A) Add aspirin ular block with sinus bradycardia. After returning to the (B) Emergent cardioversion coronary care unit, she has symptomatic intermittent 2:l (C) Increase metoprolol dosage atrioventricular block and several episodes of c<lmplete (D) Initiate oral anticoagulation heart block with a narrou, complex escape rhythrn (heart rate at 58i min). Meclications are atorvastalin. aspirin. and (E) Reassurance clopidogrel. On physical examination. blood pressure is 1lBiB2 mm FIg. pulse rate is 681min. respiration rate is lB/min. Item 84 and oxygen saturation is 96'7, with the patient breath A 55 year old man is evaluated for a 6 week history of ing ambient air. Cardiac examination reveals a regularly cough and worsening exertional dyspnea and orthopnea. irregular rhythm. The remainder ol the examination is He has heart failure, for which he has received guideline- normal. directed medical therapy for 4 months. 145

Self-Assessment Test arr .D On physical examination, blood pressure is 130/67 mm (C) Pentoxifylline D (,t Hg and pulse rate is 90/min and regular. There is an early (D) Revascularization gt .D systolic click and a holosystolic murmur loudest at the apex (E) Supervised exercise training UI UI and radiating to the back. The central venous pressure is elevated, and there are crackles at both lung bases. (D An ECG is normal. A chest radiograph reveals pulmo Item 87 nary edema. A transthoracic echocardiogram shows a left (D' A 28 year old woman r.tith Marfan syndrome is seen fol t^ ventricular ejection fraction greater than 55%. The echocar lowing recent transthoracic echocardiography obtained as diographic data are consistent with moderate mitral regur- part of a prepregnancy evaluation. Her mother has l\4arfan gitation. syndrome and had emergency surgery for ascending aortic dissection B years ago. The patient's only medication is Which of the following is the most appropriate next step in metoprolol succinate. management? On physical examination, blood pressure is 110i 60 mm (A) Cardiac magnetic resonance imaging Hg and pulse rate is 60imin and regular. The patient has (B) Repeat echocardiography in 1 year phenotypical features of Marfan syndrome. The remainder of the examination is normal. (C) Surgical mitral valve repair Transthoracic echocardiogram reveals a dilated proxi (D) Transcatheter mitral valve repair mal ascending aorta with a dimension of 4.3 cm; the dimension was 3.7 cm 1 year ago. No aortic or mitral valve regurgitation is present. Left ventricular size and func- Item 85 tion are normal. A CT scan confirms the aortic dimension A 67-year-old man is evaluated for a 3 month history of obtained by echocardiography. progressive dyspnea and peripheral edema. He also has a 6-month history of exertional chest "heaviness." Medical Which of the following is the most appropriate management? history is otherwise significant for hypertension and type 2 diabetes mellitus. He is a former cigarette smoker. quitting (A) Add atorvastatin 6 months ago. Medications are hydrochlorothiazide, ator- (B) Add losartan vastatin, metlormin, and liraglutide. (C) Aortic repair before pregnancy On physical examination, blood pressure is 122l86 mm (D) Proceed with pregnancy Hg and pulse rate is 96lmin; other vital signs are normal. BMI is 27. Jugular venous distention and an S, are present. Lower extremity edema to the mid thigh is noted. Item 88 ECG shows left bundle branch block. Echocardiogram shows ejection fraction of 25"/,, with anterior hypokinesis A 66 year old woman is evaluated for a 6 month history and normal wall thickness. of right shoulder pressure that occurs after walking half a mile and improves with 5 minutes of rest. She has no dyspnea, nausea, or tatigue. The frequency and duration of Which of the following is the most appropriate test? her symptoms have not changed. Her history is otherwise (A) Cardiac catheterization unremarkable. (B) Cardiac magnetic resonance imaging On physical examination, vital signs are normal. BMI is (C) Cardiac PET 33. Other than a paradoxically split Sr, the cardiac examina (D) Technetium 99m pyrophosphate scintigraphy tion is normal. The lungs are clear to auscultation. A chest radiograph is normal. ECG is shown (top o1' next page). Item 86 A 56 year old man is evaluated for a 3 month history of Which of the following is the most appropriate test? progressive left calf discomfort that is exacerbated when (A) Coronaryangiography walking stairs and hills and is absent at rest. Medical history (B) Exercise ECG is signiflcant for hypertension, hyperlipidemia, and coro (C) Pharmacologic myocardial perfusion imaging nary artery disease. He also has a 50 pack-year smoking history but quit smoking 3 years ago. Medications are aspi (D) Transthoracic echocardiography rin, rosuvastatin, metoprolol, and amlodipine. (E) No further testing is required On physical examination, vital signs are normal. BMI is 28. Left femoral, popliteal, and pedal pulses are faint. The ankle brachial index is 0.68 on the left and 0.98 on the right. Item 89 A .12 1.'ear old nran is evaluatcd in the eurergcncl, depart tr ment tbr pxlpitatiorls. neck pulsations. and light headedness Which of the following is the most appropriate that bcgarr,15 minlltes irgo. IIe reitorts no chest pain or management? breathlessness. He hls been unrler pressure at rtork irnd l-ras becn anxious and sleepless. llrere is no other relevant (A) CT angiography personal or familv history. He cloes not use illicit drugs or (B) Ethylenediaminetetraaceticacid supplements.

arr .D On physical examination, blood pressure is 130/67 mm (C) Pentoxifylline D (,t Hg and pulse rate is 90/min and regular. There is an early (D) Revascularization gt .D systolic click and a holosystolic murmur loudest at the apex (E) Supervised exercise training UI UI and radiating to the back. The central venous pressure is elevated, and there are crackles at both lung bases. (D An ECG is normal. A chest radiograph reveals pulmo Item 87 nary edema. A transthoracic echocardiogram shows a left (D' A 28 year old woman r.tith Marfan syndrome is seen fol t^ ventricular ejection fraction greater than 55%. The echocar lowing recent transthoracic echocardiography obtained as diographic data are consistent with moderate mitral regur- part of a prepregnancy evaluation. Her mother has l\4arfan gitation. syndrome and had emergency surgery for ascending aortic dissection B years ago. The patient's only medication is Which of the following is the most appropriate next step in metoprolol succinate. management? On physical examination, blood pressure is 110i 60 mm (A) Cardiac magnetic resonance imaging Hg and pulse rate is 60imin and regular. The patient has (B) Repeat echocardiography in 1 year phenotypical features of Marfan syndrome. The remainder of the examination is normal. (C) Surgical mitral valve repair Transthoracic echocardiogram reveals a dilated proxi (D) Transcatheter mitral valve repair mal ascending aorta with a dimension of 4.3 cm; the dimension was 3.7 cm 1 year ago. No aortic or mitral valve regurgitation is present. Left ventricular size and func- Item 85 tion are normal. A CT scan confirms the aortic dimension A 67-year-old man is evaluated for a 3 month history of obtained by echocardiography. progressive dyspnea and peripheral edema. He also has a 6-month history of exertional chest "heaviness." Medical Which of the following is the most appropriate management? history is otherwise significant for hypertension and type 2 diabetes mellitus. He is a former cigarette smoker. quitting (A) Add atorvastatin 6 months ago. Medications are hydrochlorothiazide, ator- (B) Add losartan vastatin, metlormin, and liraglutide. (C) Aortic repair before pregnancy On physical examination, blood pressure is 122l86 mm (D) Proceed with pregnancy Hg and pulse rate is 96lmin; other vital signs are normal. BMI is 27. Jugular venous distention and an S, are present. Lower extremity edema to the mid thigh is noted. Item 88 ECG shows left bundle branch block. Echocardiogram shows ejection fraction of 25"/,, with anterior hypokinesis A 66 year old woman is evaluated for a 6 month history and normal wall thickness. of right shoulder pressure that occurs after walking half a mile and improves with 5 minutes of rest. She has no dyspnea, nausea, or tatigue. The frequency and duration of Which of the following is the most appropriate test? her symptoms have not changed. Her history is otherwise (A) Cardiac catheterization unremarkable. (B) Cardiac magnetic resonance imaging On physical examination, vital signs are normal. BMI is (C) Cardiac PET 33. Other than a paradoxically split Sr, the cardiac examina (D) Technetium 99m pyrophosphate scintigraphy tion is normal. The lungs are clear to auscultation. A chest radiograph is normal. ECG is shown (top o1' next page). Item 86 A 56 year old man is evaluated for a 3 month history of Which of the following is the most appropriate test? progressive left calf discomfort that is exacerbated when (A) Coronaryangiography walking stairs and hills and is absent at rest. Medical history (B) Exercise ECG is signiflcant for hypertension, hyperlipidemia, and coro (C) Pharmacologic myocardial perfusion imaging nary artery disease. He also has a 50 pack-year smoking history but quit smoking 3 years ago. Medications are aspi (D) Transthoracic echocardiography rin, rosuvastatin, metoprolol, and amlodipine. (E) No further testing is required On physical examination, vital signs are normal. BMI is 28. Left femoral, popliteal, and pedal pulses are faint. The ankle brachial index is 0.68 on the left and 0.98 on the right. Item 89 A .12 1.'ear old nran is evaluatcd in the eurergcncl, depart tr ment tbr pxlpitatiorls. neck pulsations. and light headedness Which of the following is the most appropriate that bcgarr,15 minlltes irgo. IIe reitorts no chest pain or management? breathlessness. He hls been unrler pressure at rtork irnd l-ras becn anxious and sleepless. llrere is no other relevant (A) CT angiography personal or familv history. He cloes not use illicit drugs or (B) Ethylenediaminetetraaceticacid supplements. 146

Self-Assessment Test l,I q, F j-t (l, E aVR. vt , o vt t o, vt n II aVL v5 avF v6 vl ITEM 88

o, vt n II aVL v5 avF v6 vl ITEM 88 m On physical examination, blood pressure is 90/70 mm Central venous pressure is elevated. There are crackles at E IIg and pulse rate is 160/min; other vital signs are normal. the lung bases. c0NL 6rr*., saturation is 9B'X, with the patient breathing ambi Laboratory studies demonstrate a B-type natriuretic ent air. Intermittent cannon o waves are noted on neck peptide Ievel of 2000 pg/ml (2000 ng/L). examination. Other than a rapid regular rhythm, cardiac An ECG shows normal sinus rhythm without ST- examinatior.r is unremarkable. Lungs are c1ear. T-wave changes. An echocardiogram shows a moder ECG reveals ventricular tachycardia. He is successfully ately thickened, partially mobile aortic valve, with left cardioverted. ventricular ejection fraction of 45'/,' and hemodynamic Complete blood count and metabolic panel, including measurements compatible with Iow flow, low-gradient ! severe aortic stenosis. electrolytes, are normal. Echocardiogram and subsequent ECG are both normal. Which of the following is the most appropriate Which of the following is the most appropriate initial management? management? (A) Cardiaccatheterization (A) Cardiac magnetic resonance imaging with stress per (B) Dobutaminestressechocardiography '. fusion (C) Surgical aortic valve replacement a (B) Electrophysiologystudy (D) Transcatheter aortic valve implantation (C) lmplantable cardioverter-defibrillator (D) Implantable loop recorder Item 91 A 62-year-old woman is hospitalized for a non-ST-elevation Item 90 myocardial infarction. She has hypertension, type 2 diabe : A 76-year-old man is evaluated for a 4 week history of tes mellitus, newly symptomatic aortic stenosis, and coro- shortness of breath and chest discomfort with minimal nary artery disease, for which she underwent percutaneous exertion. Medical history is signiflcant for hlpertension, coronary intervention 1 year ago. Medications are low -dose hyperlipidemia, and coronary artery disease. Medications aspirin, ticagrelor. metoprolol, ran.ripril, metformin, and are low dose aspirin, amlodipine, atorvastatin, lisinopril, high intensity atorvastttin. and metoprolol. On physical examinatiort, vital signs are nonnal. A On physical examination, blood pressure is 135/83 grade 3/6 harsh midsystolic murnlur is noted at the right mm Hg; other vital signs are normal. Cardiac examination upper sternal border. reveals a late-peaking crescendo-decrescendo systolic mur An echocardiogram reveals normal left ventricular mur heard at the right upper sternal border with loss of Sr. ejection fraction, severe aortic stenosis, and an enlarged

m On physical examination, blood pressure is 90/70 mm Central venous pressure is elevated. There are crackles at E IIg and pulse rate is 160/min; other vital signs are normal. the lung bases. c0NL 6rr*., saturation is 9B'X, with the patient breathing ambi Laboratory studies demonstrate a B-type natriuretic ent air. Intermittent cannon o waves are noted on neck peptide Ievel of 2000 pg/ml (2000 ng/L). examination. Other than a rapid regular rhythm, cardiac An ECG shows normal sinus rhythm without ST- examinatior.r is unremarkable. Lungs are c1ear. T-wave changes. An echocardiogram shows a moder ECG reveals ventricular tachycardia. He is successfully ately thickened, partially mobile aortic valve, with left cardioverted. ventricular ejection fraction of 45'/,' and hemodynamic Complete blood count and metabolic panel, including measurements compatible with Iow flow, low-gradient ! severe aortic stenosis. electrolytes, are normal. Echocardiogram and subsequent ECG are both normal. Which of the following is the most appropriate Which of the following is the most appropriate initial management? management? (A) Cardiaccatheterization (A) Cardiac magnetic resonance imaging with stress per (B) Dobutaminestressechocardiography '. fusion (C) Surgical aortic valve replacement a (B) Electrophysiologystudy (D) Transcatheter aortic valve implantation (C) lmplantable cardioverter-defibrillator (D) Implantable loop recorder Item 91 A 62-year-old woman is hospitalized for a non-ST-elevation Item 90 myocardial infarction. She has hypertension, type 2 diabe : A 76-year-old man is evaluated for a 4 week history of tes mellitus, newly symptomatic aortic stenosis, and coro- shortness of breath and chest discomfort with minimal nary artery disease, for which she underwent percutaneous exertion. Medical history is signiflcant for hlpertension, coronary intervention 1 year ago. Medications are low -dose hyperlipidemia, and coronary artery disease. Medications aspirin, ticagrelor. metoprolol, ran.ripril, metformin, and are low dose aspirin, amlodipine, atorvastatin, lisinopril, high intensity atorvastttin. and metoprolol. On physical examinatiort, vital signs are nonnal. A On physical examination, blood pressure is 135/83 grade 3/6 harsh midsystolic murnlur is noted at the right mm Hg; other vital signs are normal. Cardiac examination upper sternal border. reveals a late-peaking crescendo-decrescendo systolic mur An echocardiogram reveals normal left ventricular mur heard at the right upper sternal border with loss of Sr. ejection fraction, severe aortic stenosis, and an enlarged 147

Self-Assessment Test rtt tr .D fi thoracic aortar the maximal diameter of the ascending aorta Item 94 D UI lll is 5.6 cm. Coronary angiography reveals diffuse in-stent A 35-year-old woman is evaluated in the emergency depart- la c0NT 1g51sn6sis of the proximal left circumflex stent (intarct- .D ment for a 1 week history of fever and chest pain. The pain UI UI related artery), focal proximal left anterior descending is sharp and midsternal, worse lying down, and improved artery stenosis. and chronic total occlusion of the right leaning forward. (D coronary artery. Coronary bypass graft surgery is planned. On physical examination, temperature is 38.5 'C l (101.3 'F), blood pressure is 120/70 mm Hg with pulsus para- .D Ut doxus of 10 mm Hg, and pulse rate is 92lmin. A three-phase Which of the following is the most appropriate additional friction rub is heard along the left sternal border and apex' intervention? ECG shows normal sinus rhythm and normal voltage (A) Ac.rrtic valve replacement with diffuse ST-segment elevation of 1 to 2 mm. An echo- cardiogram shows a pericardial eflusion without evidence (B) Aortic valve replacement and aortic repair of tamponade. (C) Transcatheter aortic valve implantation (D) No additional intervention Which of the follou'ing is the most appropriate management? (A) Discharge on ibuprofen and colchicine tr Item 92 A 38-year-old man undergoes a preoperative evaluation (B) Discharge on prednisone (C) tlospitalize and begin ibuprofen and colchicine before repair of a torn anterior cruciate ligament. His car diovascular history includes repaired tetralogy of Fallot. He (D) Hospitalize and begin methylprednisolone has no symptoms. On physical examination, vital signs are normal. Jugular venous distention and a prominent o wave are noted. A right ventricular heave is present. A single S, is heard, as is a grade 1/6 early systolic murmur local- Item 95 A S7-year-old man is evaluated in the emergency depart- tr ment af'ter a cardiac arrest. Bystander cardiopulmonary ized to the left second intercostal space and a grade 2/6 resuscitation and use of an automated external deflbrillator diastolic murmur best heard in the left second and third resulted in a return of sinus rhythm. An initial ECG revealed intercostal spaces. The diastolic murmur increases with ST-segment depression in leads Vr and Vu. After irritiation of inspiration. aspirin, unfractionated heparin, and ticagrelor, angiogra phy revealed no significant obstructive lesions. He is admit- Which of the following is the most likely diagnosis? ted to a monitored bed, where he develops acute persistent (A) Aortic coarctation chest pain, hypotension, and the ECG changes shown. (B) Aorticregurgitation (C) Mitral stenosis (D) Pulmonaryregurgitation

tr .D fi thoracic aortar the maximal diameter of the ascending aorta Item 94 D UI lll is 5.6 cm. Coronary angiography reveals diffuse in-stent A 35-year-old woman is evaluated in the emergency depart- la c0NT 1g51sn6sis of the proximal left circumflex stent (intarct- .D ment for a 1 week history of fever and chest pain. The pain UI UI related artery), focal proximal left anterior descending is sharp and midsternal, worse lying down, and improved artery stenosis. and chronic total occlusion of the right leaning forward. (D coronary artery. Coronary bypass graft surgery is planned. On physical examination, temperature is 38.5 'C l (101.3 'F), blood pressure is 120/70 mm Hg with pulsus para- .D Ut doxus of 10 mm Hg, and pulse rate is 92lmin. A three-phase Which of the following is the most appropriate additional friction rub is heard along the left sternal border and apex' intervention? ECG shows normal sinus rhythm and normal voltage (A) Ac.rrtic valve replacement with diffuse ST-segment elevation of 1 to 2 mm. An echo- cardiogram shows a pericardial eflusion without evidence (B) Aortic valve replacement and aortic repair of tamponade. (C) Transcatheter aortic valve implantation (D) No additional intervention Which of the follou'ing is the most appropriate management? (A) Discharge on ibuprofen and colchicine tr Item 92 A 38-year-old man undergoes a preoperative evaluation (B) Discharge on prednisone (C) tlospitalize and begin ibuprofen and colchicine before repair of a torn anterior cruciate ligament. His car diovascular history includes repaired tetralogy of Fallot. He (D) Hospitalize and begin methylprednisolone has no symptoms. On physical examination, vital signs are normal. Jugular venous distention and a prominent o wave are noted. A right ventricular heave is present. A single S, is heard, as is a grade 1/6 early systolic murmur local- Item 95 A S7-year-old man is evaluated in the emergency depart- tr ment af'ter a cardiac arrest. Bystander cardiopulmonary ized to the left second intercostal space and a grade 2/6 resuscitation and use of an automated external deflbrillator diastolic murmur best heard in the left second and third resulted in a return of sinus rhythm. An initial ECG revealed intercostal spaces. The diastolic murmur increases with ST-segment depression in leads Vr and Vu. After irritiation of inspiration. aspirin, unfractionated heparin, and ticagrelor, angiogra phy revealed no significant obstructive lesions. He is admit- Which of the following is the most likely diagnosis? ted to a monitored bed, where he develops acute persistent (A) Aortic coarctation chest pain, hypotension, and the ECG changes shown. (B) Aorticregurgitation (C) Mitral stenosis (D) Pulmonaryregurgitation Item 93 l A S9-year old man is evaluated during a routine visit. He has type 2 diabetes mellitus. One year ago, he had an athero- sclerotic stroke with no residual neurologic deflcits. Medica- tions are aspirin, metformin, candesartan, and rosuvastatin. He remains active and has no symptoms. On physical examination, blood pressure is 132/80 mm Hg; other vital signs are normal. BMI is 25. The remainder of the examination is unremarkable. Laboratory studies show a serum LDL cholesterol level vl- of 66 mg/dl (t.Zt mmol/L) and an estimated glomerular flltration rate of 60 ml/min 11.73 m2. A hemoglobin Ar. level measured 3 months ago was 6.8%.

Item 93 l A S9-year old man is evaluated during a routine visit. He has type 2 diabetes mellitus. One year ago, he had an athero- sclerotic stroke with no residual neurologic deflcits. Medica- tions are aspirin, metformin, candesartan, and rosuvastatin. He remains active and has no symptoms. On physical examination, blood pressure is 132/80 mm Hg; other vital signs are normal. BMI is 25. The remainder of the examination is unremarkable. Laboratory studies show a serum LDL cholesterol level vl- of 66 mg/dl (t.Zt mmol/L) and an estimated glomerular flltration rate of 60 ml/min 11.73 m2. A hemoglobin Ar. level measured 3 months ago was 6.8%. Which of the following is the most appropriate management of this patient's atherosclerotic Blood pressure is 95/60 mm Hg, pulse rate is 55/min, cardiovascular disease? respiration rate is 24lmin, and oxygen saturation is 96'2, (A) Begin empagliflozin with the patient breathing ambient air. Cardiac examina- (B) Begin ezetimibe tion is normal. tsibasilar pulmonary crackles are present. The initial high-sensitivity troponin level is elevated (C) Obtain exercise ECG (>99th percentile upper reference limit); urine toxicology (D) No changes in management screen is negative for drugs. 148

Self-Assessment Test UI Fc, tr CONI. Follow-ing intravenous nitrclglycerin, blood pressure increases and chest pain subsides. Follow-up ECG is shown. atrial fibrillation is diagnosed. He also has chronic lympho- cytic leukemia. He began ibrutinib 1 month ago. On physical examination, pulse rate is 128/min and E q, tr irregularly irregular. Oxygen saturation is 95'X, u'ith the U! UI patient breathing ambient air. Other than a rapid, irregular o t rhythm, the cardiopulmonary examination is normal. Sple UI nomegaly is present. There is no lower extremity edema. Laboratory studies show a nclrmal D-dimer level. The g(, initial high sensitivity cardiac troponin level is normal vt (<99th percentile upper rel'erence limit). Thyroid-stimulating hormone and free thyroxine levels are normal. ECG shows atrial flbrillation with rapid ventricular response. nonspecific ST-T abnorrnality, and incomplete right bundle branch block. Echocardiogram shows normal biventricular size and f'unction. normal valvular structure and function. and normal atrial size.

UI Fc, tr CONI. Follow-ing intravenous nitrclglycerin, blood pressure increases and chest pain subsides. Follow-up ECG is shown. atrial fibrillation is diagnosed. He also has chronic lympho- cytic leukemia. He began ibrutinib 1 month ago. On physical examination, pulse rate is 128/min and E q, tr irregularly irregular. Oxygen saturation is 95'X, u'ith the U! UI patient breathing ambient air. Other than a rapid, irregular o t rhythm, the cardiopulmonary examination is normal. Sple UI nomegaly is present. There is no lower extremity edema. Laboratory studies show a nclrmal D-dimer level. The g(, initial high sensitivity cardiac troponin level is normal vt (<99th percentile upper rel'erence limit). Thyroid-stimulating hormone and free thyroxine levels are normal. ECG shows atrial flbrillation with rapid ventricular response. nonspecific ST-T abnorrnality, and incomplete right bundle branch block. Echocardiogram shows normal biventricular size and f'unction. normal valvular structure and function. and normal atrial size. Which of the following is the most likely contributor to I the patient's atrial fitrrillation? (A) Acute myocardial infarction (B) lbrutinib (C) Pulmonarythromboembolism (D) Thyrotoxicosis Which of the following is the most likely diagnosis? I (A) Coronary embolism

Which of the following is the most likely contributor to I the patient's atrial fitrrillation? (A) Acute myocardial infarction (B) lbrutinib (C) Pulmonarythromboembolism (D) Thyrotoxicosis Which of the following is the most likely diagnosis? I (A) Coronary embolism ( (B) Coronaryvasospasm (C) Pulmonary embolism ttem 98 A 71'year old woman is hospitalized with cardiogenic tr (D) Stress (takotsubo) cardiomyopathy shock. On physical examination, blocld pressure is B7l51 mm Hg, pulse rate is 112/min, respiration rate is 22lmin, and Item 96 oxygen saturation is 92')(, with the patient breathing 40')(, Fror. An S.,, jugular venous distention, pulmonary crackles, A 68-year-old man is evaluated for increasingly frequent ar,d cool extremities are present. angina. One month ago, coronary angiography was per- formed because of the occurrence of angina at lower levels of Laboratory studies show an elevated seruln high- sensitivity cardiac troponin level (>9gth percentile upper exertion. It showed diffuse coronary disease without lesions ref'erence limit) and serum creatinine level of t.8 mg/dl amenable to revascularization and preserved left ventricu- (ls9 Uraoli L). lar function. Following coronary angiography, the patient An ECC demonstrates 2-mm ST-segment depressions increased his dosage of isosorbide mononitrate to twice in leads V., through V,,. daily; however, his exertional chest discomfort worsened. Emergent cardiac catheterization shows critical lesions He also has hypertension and diabetes mellitus. Previously, in the left ilnterior descending and circumflex arteries, and diltiazem was substituted for metoprolol because of intoler- stents are placed. Following stenting, the patient's clinical ance. Medications are aspirin, metformin, liraglutide, ator- status is unchanged. vastatin, lisinopril, diltiazem, and isosorbide mononitrate. Medications are aspirin. prasugrel, f'urosemide, and On physical examination, blood pressure is 135/80 mm norepinephrine. Hg, pulse rate is 67lmin, and respiration rate is l8/min. The remainder of the examination is unremarkable. ECG shows sinus rhythm and nonspeciflc intraventric- Which of the following is the most appropriate additional ular conduction delay, unchanged from 1 month ago. management? (A) Digoxin Which of the following is the most appropriate management? (B) Intra'aortic balloon pump placement (A) Add amlodipine (C) N4etoprolol (B) Decrease Iisinopril dosage (D) Urgent cardiac transplantation (C) Reduce isosorbide mononitrate dosage to once daily (Fl) Vasopressin (D) Repeatcoronaryangiography

( (B) Coronaryvasospasm (C) Pulmonary embolism ttem 98 A 71'year old woman is hospitalized with cardiogenic tr (D) Stress (takotsubo) cardiomyopathy shock. On physical examination, blocld pressure is B7l51 mm Hg, pulse rate is 112/min, respiration rate is 22lmin, and Item 96 oxygen saturation is 92')(, with the patient breathing 40')(, Fror. An S.,, jugular venous distention, pulmonary crackles, A 68-year-old man is evaluated for increasingly frequent ar,d cool extremities are present. angina. One month ago, coronary angiography was per- formed because of the occurrence of angina at lower levels of Laboratory studies show an elevated seruln high- sensitivity cardiac troponin level (>9gth percentile upper exertion. It showed diffuse coronary disease without lesions ref'erence limit) and serum creatinine level of t.8 mg/dl amenable to revascularization and preserved left ventricu- (ls9 Uraoli L). lar function. Following coronary angiography, the patient An ECC demonstrates 2-mm ST-segment depressions increased his dosage of isosorbide mononitrate to twice in leads V., through V,,. daily; however, his exertional chest discomfort worsened. Emergent cardiac catheterization shows critical lesions He also has hypertension and diabetes mellitus. Previously, in the left ilnterior descending and circumflex arteries, and diltiazem was substituted for metoprolol because of intoler- stents are placed. Following stenting, the patient's clinical ance. Medications are aspirin, metformin, liraglutide, ator- status is unchanged. vastatin, lisinopril, diltiazem, and isosorbide mononitrate. Medications are aspirin. prasugrel, f'urosemide, and On physical examination, blood pressure is 135/80 mm norepinephrine. Hg, pulse rate is 67lmin, and respiration rate is l8/min. The remainder of the examination is unremarkable. ECG shows sinus rhythm and nonspeciflc intraventric- Which of the following is the most appropriate additional ular conduction delay, unchanged from 1 month ago. management? (A) Digoxin Which of the following is the most appropriate management? (B) Intra'aortic balloon pump placement (A) Add amlodipine (C) N4etoprolol (B) Decrease Iisinopril dosage (D) Urgent cardiac transplantation (C) Reduce isosorbide mononitrate dosage to once daily (Fl) Vasopressin (D) Repeatcoronaryangiography Item 99 Item 97 A 66-year-old man is seen in the office after hospitaliza A 70-year-old man is evaluated in the emergency depart tion for an embolic stroke 7 days ago. His initial neurologic ment for 3 days of palpitations and dyspnea. New-onset flndings were minimal and have since resolved. An embolic

Item 99 Item 97 A 66-year-old man is seen in the office after hospitaliza A 70-year-old man is evaluated in the emergency depart tion for an embolic stroke 7 days ago. His initial neurologic ment for 3 days of palpitations and dyspnea. New-onset flndings were minimal and have since resolved. An embolic 149

Self-Assessment Test 1 ut (D source has not been identifled. He has no other pertinent Item 102 la personal or family history. Medications are aspirin and UI An 80 year old man is evaluated for a 6-week history of (D clopidogrel. la resting right foot and flrst toe pain. He has type 2 diabe tt Physical examination, including vital signs and neuro tes mellitus, hypertension, and hyperlipidemia. He has a logic examination, is normal. SO-pack-year smoking history but quit 10 years ago. Med- .D Ambulatory 4S-hour ECG monitoring showed no ications are low-dose aspirin, metformin, lisinopril, and { .D arrhythmias. atorvastatin. l^ On physical examination, vital signs are normal. The Which of the following is the most reasonable management? right foot is pale and mottled. A 4 x 4 cm ulceration is (A) Discontinue aspirin and clopidogrel; begin warfarin noted on the lateral aspect ofthe right flfth metatarsal. Pedal pulses are diminished on the left and absent on the right. (B) Left atrial appendage occlusion The ankle-brachial index is 0.62 on the left and 0.44 on (C) Loop recorder implantation the right. (D) Test for thrombophilia Which ofthe following is the most appropriate next step in management? Item 10O A S5-year-old man is evaluated for easy bruising. The patient (A) CT angiography underwent mechanical mitral valve replacement l year ago. (B) Hyperbaric oxygen treatment He reports no bleeding. His only medication is warfarin. (C) Invasiveangiography On physical examination, vital signs are normal. Car- (D) Primarybelow-the-knee amputation 1 diac examination reveals a normal mechanical valve sound without murmur. The remainder of the cardiopulmonary examination is normal. Examination of the arms reveals Item 103 numerous ecchymoses. A 42 year old woman is evaluated for an episode of syncope Laboratory studies reveal a normal hemoglobin level; that occurred 2 weeks ago while she was hurrying to catch INR is 3.4 and has ranged between 2.6 and 3.5 over the past a bus. She has hypertrophic cardiomyopathy. Before this 3 months. episode, her symptoms had been very well controlled. She continues to accomplish activities of daily living with only Which of the following is the most appropriate treatment? occasional mild dyspnea. She has no family history of sud- (A) Continue current warfarin dosage den cardiac death. Her only medication is metoprolol. (B) Decrease warfarin dosage Twenty-four-hour ambulatory ECG monitoring shows one three beat run of nonsustained ventricular tachycar (C) Discontinue warfarin and start aspirin dia. Echocardiogram shows maximum left ventricular wall (D) Discontinue warfarin and start dabigatran thickness of 30 mm, asymmetric septal hypertrophy, and (E) Discontinue warfarin and start rivaroxaban systolic anterior motion of the mitral valve. Resting lelt ventricular outflow tract gradient is 24 mm Hg, increasing to 36 mm Hg during Valsalva maneuver. Item 101 A SO-year-old man is evaluated for 8 weeks of progressive Which of the following is the most appropriate treatment? exertional dyspnea and a syncopal event. He has been well (A) Disopyramide :

ut (D source has not been identifled. He has no other pertinent Item 102 la personal or family history. Medications are aspirin and UI An 80 year old man is evaluated for a 6-week history of (D clopidogrel. la resting right foot and flrst toe pain. He has type 2 diabe tt Physical examination, including vital signs and neuro tes mellitus, hypertension, and hyperlipidemia. He has a logic examination, is normal. SO-pack-year smoking history but quit 10 years ago. Med- .D Ambulatory 4S-hour ECG monitoring showed no ications are low-dose aspirin, metformin, lisinopril, and { .D arrhythmias. atorvastatin. l^ On physical examination, vital signs are normal. The Which of the following is the most reasonable management? right foot is pale and mottled. A 4 x 4 cm ulceration is (A) Discontinue aspirin and clopidogrel; begin warfarin noted on the lateral aspect ofthe right flfth metatarsal. Pedal pulses are diminished on the left and absent on the right. (B) Left atrial appendage occlusion The ankle-brachial index is 0.62 on the left and 0.44 on (C) Loop recorder implantation the right. (D) Test for thrombophilia Which ofthe following is the most appropriate next step in management? Item 10O A S5-year-old man is evaluated for easy bruising. The patient (A) CT angiography underwent mechanical mitral valve replacement l year ago. (B) Hyperbaric oxygen treatment He reports no bleeding. His only medication is warfarin. (C) Invasiveangiography On physical examination, vital signs are normal. Car- (D) Primarybelow-the-knee amputation 1 diac examination reveals a normal mechanical valve sound without murmur. The remainder of the cardiopulmonary examination is normal. Examination of the arms reveals Item 103 numerous ecchymoses. A 42 year old woman is evaluated for an episode of syncope Laboratory studies reveal a normal hemoglobin level; that occurred 2 weeks ago while she was hurrying to catch INR is 3.4 and has ranged between 2.6 and 3.5 over the past a bus. She has hypertrophic cardiomyopathy. Before this 3 months. episode, her symptoms had been very well controlled. She continues to accomplish activities of daily living with only Which of the following is the most appropriate treatment? occasional mild dyspnea. She has no family history of sud- (A) Continue current warfarin dosage den cardiac death. Her only medication is metoprolol. (B) Decrease warfarin dosage Twenty-four-hour ambulatory ECG monitoring shows one three beat run of nonsustained ventricular tachycar (C) Discontinue warfarin and start aspirin dia. Echocardiogram shows maximum left ventricular wall (D) Discontinue warfarin and start dabigatran thickness of 30 mm, asymmetric septal hypertrophy, and (E) Discontinue warfarin and start rivaroxaban systolic anterior motion of the mitral valve. Resting lelt ventricular outflow tract gradient is 24 mm Hg, increasing to 36 mm Hg during Valsalva maneuver. Item 101 A SO-year-old man is evaluated for 8 weeks of progressive Which of the following is the most appropriate treatment? exertional dyspnea and a syncopal event. He has been well (A) Disopyramide : otherwise and takes no medications. On physical examination, vital signs are normal. Car (B) Implantable cardioverter-deflbrillator diac examination reveals a late-peaking systolic crescendo (C) Septal reduction therapy decrescendo murmur heard at the right upper sternal (D) Verapamil border with loss of Sr. The remainder of the examination is normal. An ECG shows normal sinus rhythm and left ventricu Iar hypertrophy with repolarization abnormalities. An echocardiogram shows a severely thickened, min- Item 104 477 year old ra,,oman is hospitalized for intennittent recur tr rent chest pain. Her ECG is shon'n (top of next page). imally mobile bicuspid aortic valve. Hemodynamic mea The patient had a moderately severe ischemic stroke surements on echocardiogram are consistent with severe 2 years ago and has oxygen dependent COPD. Nledications aortic stenosis and normal left ventricular function. The are aspirin, atorvastatin, and inhaled albuterol and tiotro ascending aorta could not be adequately assessed. pium. On physical examination. blood pressure is 145 85 mm Which ofthe following is the most appropriate management? Hg, pulse rate is 82'min, and respiration rate is 18 n1in. (A) Cardiac catheterization Oxygen saturation is 909i on 2 L ofoxl,gen by nasal cannula. (B) CT angiography of the thoracic aorta BMI is 18. An erpiratory wheeze is heard on auscultation of the lungs. Cardiac examination reveals an Sr. Estimated (C) Exercise treadmill stress testing central venous pressure is 10 cm HrO. Minimal left-sided (D) Transcatheter aortic valve implantation weakness is present.

otherwise and takes no medications. On physical examination, vital signs are normal. Car (B) Implantable cardioverter-deflbrillator diac examination reveals a late-peaking systolic crescendo (C) Septal reduction therapy decrescendo murmur heard at the right upper sternal (D) Verapamil border with loss of Sr. The remainder of the examination is normal. An ECG shows normal sinus rhythm and left ventricu Iar hypertrophy with repolarization abnormalities. An echocardiogram shows a severely thickened, min- Item 104 477 year old ra,,oman is hospitalized for intennittent recur tr rent chest pain. Her ECG is shon'n (top of next page). imally mobile bicuspid aortic valve. Hemodynamic mea The patient had a moderately severe ischemic stroke surements on echocardiogram are consistent with severe 2 years ago and has oxygen dependent COPD. Nledications aortic stenosis and normal left ventricular function. The are aspirin, atorvastatin, and inhaled albuterol and tiotro ascending aorta could not be adequately assessed. pium. On physical examination. blood pressure is 145 85 mm Which ofthe following is the most appropriate management? Hg, pulse rate is 82'min, and respiration rate is 18 n1in. (A) Cardiac catheterization Oxygen saturation is 909i on 2 L ofoxl,gen by nasal cannula. (B) CT angiography of the thoracic aorta BMI is 18. An erpiratory wheeze is heard on auscultation of the lungs. Cardiac examination reveals an Sr. Estimated (C) Exercise treadmill stress testing central venous pressure is 10 cm HrO. Minimal left-sided (D) Transcatheter aortic valve implantation weakness is present. 150

Self-Assessment Test t (l, t- I AvR V1 (u .,I ra q, tt UI q, rrt II v2 III II ITEM 104

.,I ra q, tt UI q, rrt II v2 III II ITEM 104 'lhe initiai high-sensitivity troponin level is elevated tr CONT (>99th percentile upper reference limit). lntravenous unfractionated heparin is initiated, and Item 105 A 74-year-old man is evaluated for shortness of breath that occurs when walking around the house and occasionally coronary angiography is planned fbr the morning. when getting dressed. History is significant for ischemic car diomyopathy and three heart failure hospitalDations over Which of the following is the most appropriate additional the past 6 months. He was treated for colon cancer 2 years treatment? agoi there is no evidence of recurrence. He has an implant (A) Clopidogrel able cardioverter defibrillator. Medications are lisinopril, (B) Prasugrel high dose furosemide, and spironolactone. He previously took carvedilol and isosorbide dinitrate hydralazine, which (C) Reteplase were discontinued because of symptomatic hypotension. (D) f irofiban On physical examination, blood pressure is 94166 mm Hg and pulse rate is BB/min. Cardiac examination reveals

'lhe initiai high-sensitivity troponin level is elevated tr CONT (>99th percentile upper reference limit). lntravenous unfractionated heparin is initiated, and Item 105 A 74-year-old man is evaluated for shortness of breath that occurs when walking around the house and occasionally coronary angiography is planned fbr the morning. when getting dressed. History is significant for ischemic car diomyopathy and three heart failure hospitalDations over Which of the following is the most appropriate additional the past 6 months. He was treated for colon cancer 2 years treatment? agoi there is no evidence of recurrence. He has an implant (A) Clopidogrel able cardioverter defibrillator. Medications are lisinopril, (B) Prasugrel high dose furosemide, and spironolactone. He previously took carvedilol and isosorbide dinitrate hydralazine, which (C) Reteplase were discontinued because of symptomatic hypotension. (D) f irofiban On physical examination, blood pressure is 94166 mm Hg and pulse rate is BB/min. Cardiac examination reveals tr Item 1O5 A 73 year oldwoman is evaluated in the emergencydepart an S. but no jugular venous distention or dependent edema. Laboratory studies show a serum creatinine Ievel of 1.7 mgldL (150 pmol/L) and a serum sodium level of ment fbr a 1 day history of recurrent ischemic chest pain. 'lhe last episode began 30 minutes ago and is ongoing despite 132 mEqrL (132 mmol L). Echocardiogram performed during his last hospitaliza escalating doses of sublingual ancl parenteral nitroglycerin. tion showed an ejection fraction of l0'7,. History is signiflcant for hypertension and dyslipidemia. The patient is engaged in a discussion regarding man Medications are enalapril and atorvastatin. agement options. On physical examination, blood pressure is 119184 mm Hg, and pulse rate is 104/min. Other than an S.,, the cardio pulmonary examination is normal. Which of the following is the most reasonable next step in The flrst set of cardiac biomarker levels is normal. management? ECG shows sinus tachycarclia and new 2 mm ST (A) Heart transplant segnlent depressions in the inf'erior leads. (B) Hospitalization Which of the following is the most appropriate imagtng (C) Left ventricular assist device placement test in this patient? (D) Low dose P blocker (A) Coronary artery calcium scoring (B) CoronaryCTangiography Item 107 (C) lnvasive coronary angittgraphy A 69-year old woman is evaluated during a follow up visit (D) Transthoracic echocardiography 7 months after coronary stent placement for non ST-elevation

tr Item 1O5 A 73 year oldwoman is evaluated in the emergencydepart an S. but no jugular venous distention or dependent edema. Laboratory studies show a serum creatinine Ievel of 1.7 mgldL (150 pmol/L) and a serum sodium level of ment fbr a 1 day history of recurrent ischemic chest pain. 'lhe last episode began 30 minutes ago and is ongoing despite 132 mEqrL (132 mmol L). Echocardiogram performed during his last hospitaliza escalating doses of sublingual ancl parenteral nitroglycerin. tion showed an ejection fraction of l0'7,. History is signiflcant for hypertension and dyslipidemia. The patient is engaged in a discussion regarding man Medications are enalapril and atorvastatin. agement options. On physical examination, blood pressure is 119184 mm Hg, and pulse rate is 104/min. Other than an S.,, the cardio pulmonary examination is normal. Which of the following is the most reasonable next step in The flrst set of cardiac biomarker levels is normal. management? ECG shows sinus tachycarclia and new 2 mm ST (A) Heart transplant segnlent depressions in the inf'erior leads. (B) Hospitalization Which of the following is the most appropriate imagtng (C) Left ventricular assist device placement test in this patient? (D) Low dose P blocker (A) Coronary artery calcium scoring (B) CoronaryCTangiography Item 107 (C) lnvasive coronary angittgraphy A 69-year old woman is evaluated during a follow up visit (D) Transthoracic echocardiography 7 months after coronary stent placement for non ST-elevation 151

.) Self-Assessment Test UI .D tt tt myocardial infarction. History is also notable for paroxys- mal atrial flbrillation, hypertension, and gastrointestinal bleeding due to diverticulosis 5 years ago. Medications are Item 1 10 A 56 year old man is hospitalized for an ST elevation m1'o tr .D t^ cardial infarction. He is treated with percutaneous coronary l UI aspirin, clopidogrel, rivaroxaban, metoprolol, lisinopril, intervention and is now asymptomatic. Medical history is 3 and rosuvastatin. significant for hypertension and paroxysmal atrial fibrilla \ .D On physical examination, vital signs are normal. The tion. Outpatient n-redications are flecainide. rivaroxaban. = patient weighs B0 kg (u6.4 lb). Bruising is present on the t metoprolol. and lisinopril. o lrt arms and legs. The remainder of the examination is unre- A predischarge ECG shows sinus rh1'thm (heart rate. markable. 58 min). a QRS complex duration o1 124 ms, and a right Serum creatinine level is 1.0 mg/dl (88.a pmol/L). bundle branch block pattern. An echocardiogram reveals a mildly reduced left ventricular ejection fraction $'ith an Which ofthe following is the most appropriate inferior u'al1 motion abnormalitv. 1 management? (A) Discontinueaspirin Which of the following is the most appropriate :

tt tt myocardial infarction. History is also notable for paroxys- mal atrial flbrillation, hypertension, and gastrointestinal bleeding due to diverticulosis 5 years ago. Medications are Item 1 10 A 56 year old man is hospitalized for an ST elevation m1'o tr .D t^ cardial infarction. He is treated with percutaneous coronary l UI aspirin, clopidogrel, rivaroxaban, metoprolol, lisinopril, intervention and is now asymptomatic. Medical history is 3 and rosuvastatin. significant for hypertension and paroxysmal atrial fibrilla \ .D On physical examination, vital signs are normal. The tion. Outpatient n-redications are flecainide. rivaroxaban. = patient weighs B0 kg (u6.4 lb). Bruising is present on the t metoprolol. and lisinopril. o lrt arms and legs. The remainder of the examination is unre- A predischarge ECG shows sinus rh1'thm (heart rate. markable. 58 min). a QRS complex duration o1 124 ms, and a right Serum creatinine level is 1.0 mg/dl (88.a pmol/L). bundle branch block pattern. An echocardiogram reveals a mildly reduced left ventricular ejection fraction $'ith an Which ofthe following is the most appropriate inferior u'al1 motion abnormalitv. 1 management? (A) Discontinueaspirin Which of the following is the most appropriate : (B) Discontinuerivaroxaban management? (C) Switch rivaroxaban to reduced-dose apixaban (A) Ambulatory ECG monitoring (D) Switch rivaroxaban to warfarin (B) Discontinueflecainide (C) Discontinuemetoprolol I : Item 108 (D) Exercise stress testing \ A 35 year-old man is evaluated during a routine offlce visit. t He underwent atrial septal defect closure with a transcath eter device l year ago. His past medical history is otherwise Item 111 :

(B) Discontinuerivaroxaban management? (C) Switch rivaroxaban to reduced-dose apixaban (A) Ambulatory ECG monitoring (D) Switch rivaroxaban to warfarin (B) Discontinueflecainide (C) Discontinuemetoprolol I : Item 108 (D) Exercise stress testing \ A 35 year-old man is evaluated during a routine offlce visit. t He underwent atrial septal defect closure with a transcath eter device l year ago. His past medical history is otherwise Item 111 : : unremarkable, and he has no other medical problems. He A 78 year old woman is evaluated during follow up of takes no medications. nonischemic heart failure with reduced ejection fraction On physical examination, vital signs and the remainder diagnosed 6 months ago. She has New York Heart Associa of the examination are normal. tion functional class III symptoms. She is receiving optimal I The patient will have periodontal cleaning next week. guideline-directed medical therapy consisting of valsartan- sacubitril, carvedilol, spironolactone, and furosemide. Which ofthe following is the most appropriate endocarditis On physical examination, blood pressure is lo4l62 prophylaxis? mm Hg and pulse rate is 58/min. A grade 2/6 holosystolic murmur is heard at the apex, and a grade 1/6 crescendo (A) Amoxicillin decrescendo systolic murrnur is heard at the base. There is (B) Azithromycin no jugular venous distention or peripheral edema. (C) Ceftriaxone ECG shows sinus rhythm and left bundle branch block (D) Clindamycin with QRS duration of 155 ms. Echocardiogram shows an (E) No endocarditis prophylaxis ejection fraction of 307,, left ventricular end systolic dimen- sion of 53 mm, mild to moderate mitral regurgitation, and mild aortic stenosis. Item 109 i A 63 year-old man is evaluated during a follow-up exam- Which of the following is the most appropriate treatment? t ination for rheumatic aortic valve disease. He is asymptom (A) Cardiacresynchronizationtherapy atic and has no exercise limitations. He has no other medical problems. (B) Ivabradine :

: unremarkable, and he has no other medical problems. He A 78 year old woman is evaluated during follow up of takes no medications. nonischemic heart failure with reduced ejection fraction On physical examination, vital signs and the remainder diagnosed 6 months ago. She has New York Heart Associa of the examination are normal. tion functional class III symptoms. She is receiving optimal I The patient will have periodontal cleaning next week. guideline-directed medical therapy consisting of valsartan- sacubitril, carvedilol, spironolactone, and furosemide. Which ofthe following is the most appropriate endocarditis On physical examination, blood pressure is lo4l62 prophylaxis? mm Hg and pulse rate is 58/min. A grade 2/6 holosystolic murmur is heard at the apex, and a grade 1/6 crescendo (A) Amoxicillin decrescendo systolic murrnur is heard at the base. There is (B) Azithromycin no jugular venous distention or peripheral edema. (C) Ceftriaxone ECG shows sinus rhythm and left bundle branch block (D) Clindamycin with QRS duration of 155 ms. Echocardiogram shows an (E) No endocarditis prophylaxis ejection fraction of 307,, left ventricular end systolic dimen- sion of 53 mm, mild to moderate mitral regurgitation, and mild aortic stenosis. Item 109 i A 63 year-old man is evaluated during a follow-up exam- Which of the following is the most appropriate treatment? t ination for rheumatic aortic valve disease. He is asymptom (A) Cardiacresynchronizationtherapy atic and has no exercise limitations. He has no other medical problems. (B) Ivabradine : On physical examination, blood pressure is 134/32 mm (C) Mitral valve clip placement Hg. A grade 3/6 holodiastolic murmur is heard best at the (D) Transcatheter aortic valve implantation left sternal border. Peripheral pulses are bounding. There is no evidence ofheart failure. A transthoracic echocardiogram with good image qual- Item 112 ity shows a left ventricular ejection fraction greater than a A S8-year-old man with stable exertional angina returns 55'1, and a tricuspid aortic valve with severe aortic regur- for follow-up evaluation. He has normal left ventricular -a gitation. The left ventricular end systolic dimension is ele function and no high-risk features on exercise ECG. Angina vated at 45 mm. symptoms include chest pressure that routinely occurs while walking 25 yards despite maximally tolerated medi- Which of the following is the most appropriate cal therapy. Medications are aspirin, metoprolol, isosorbide management? mononitrate, and atorvastatin. (A) Repeat evaluation in 6 months On physical examination, blood pressure is 110/70 mm (B) Surgical aortic valve replacement Hg, pulse rate is 54/min, and respiration rate is 16/min. BMI is 25. (C) Transcatheter aortic valve implantation A coronary angiogram shows a 70% proximal right cor- (D) Transesophageal echocardiography onary artery stenosis and an 80'/n second obtuse marginal

On physical examination, blood pressure is 134/32 mm (C) Mitral valve clip placement Hg. A grade 3/6 holodiastolic murmur is heard best at the (D) Transcatheter aortic valve implantation left sternal border. Peripheral pulses are bounding. There is no evidence ofheart failure. A transthoracic echocardiogram with good image qual- Item 112 ity shows a left ventricular ejection fraction greater than a A S8-year-old man with stable exertional angina returns 55'1, and a tricuspid aortic valve with severe aortic regur- for follow-up evaluation. He has normal left ventricular -a gitation. The left ventricular end systolic dimension is ele function and no high-risk features on exercise ECG. Angina vated at 45 mm. symptoms include chest pressure that routinely occurs while walking 25 yards despite maximally tolerated medi- Which of the following is the most appropriate cal therapy. Medications are aspirin, metoprolol, isosorbide management? mononitrate, and atorvastatin. (A) Repeat evaluation in 6 months On physical examination, blood pressure is 110/70 mm (B) Surgical aortic valve replacement Hg, pulse rate is 54/min, and respiration rate is 16/min. BMI is 25. (C) Transcatheter aortic valve implantation A coronary angiogram shows a 70% proximal right cor- (D) Transesophageal echocardiography onary artery stenosis and an 80'/n second obtuse marginal 152

Self-Assessment Test vt artery stenosis. The left anterior descending artery has non- G' Item 1 14 F obstructive lesions in the proximal segment. A 65-year-old woman is evaluated in the oIflce after several (l, visits to the emergency department for paroxysmal atrial Which of the following beneflts can the patient expect flbrillation and acute heart failure. Medications are apix- UI UI following coronary artery bypass grafting? aban, metoprolol, furosemide, and losartan. c, UI UI (A) Discontinuation of cardioprotective medications Vital signs are normal. Cardiopulmonary examination (B) Improvement in symptoms and the remainder of the physical examination are normal. Results of laboratory studies show a normal serum o t! (C) Increased survival thyroid-stimulating hormone level. (D) Reduced risk for myocardial infarction An ECG shows sinus rhythm with a heart rate of 58/min. An echocardiogram reveals a left ventricular ejec- tion fraction of 45%. Item 1 13 A 30 year-old man is seen in the offlce for slowly pro- Which of the following is the most appropriate gressive dyspnea that flrst appeared when walking rap- treatment? idly or uphill. He denies orthopnea, palpitations, or chest pain. He has no other medical problems and takes no (A) Atrioventricular node ablation with permanent pace- medications. maker implantation On physical examination, vital signs are normal. (B) Implantable cardioverter-deflbrillator placement Jugular venous distention is present. There is a left para- (C) Left atrial appendage occlusion sternal impulse. A grade 2/6 systolic murmur is heard (D) Rhythm control at the second left intercostal space, and a diastolic flow rumble is heard over the tricuspid valve. Fixed splitting of the S, is present. The remainder of the examination is normal. An ECG is shown. Chest radiograph reveals right heart Item 1 15 A 57 year old man is evaluated in the emergency department tr tbr sudden onset anterior chest pain. He has hypertension, enlargement, a prominent pulmonary artery, and increased hyperlipidemia, and coronary artery disease. Medications pulmonary vascularity. are hydrochlorothiazide. aspirin, amlodipine, olmesartan, labetalol, and atorvastatin. Which of the following is the most likely diagnosis? On physical examination, blood pressure is 172i 64 mm (A) Atrial septal defect IJg in the right arm and 135/63 mm I{g in the left arm, pulse (B) Bicuspid aortic valve with aortic regurgitation rate is 110/min, respiration rate is 24lmin, and oxygen sat- uration with the patient breathing ambient air is 96'X,. Car (C) Mitral stenosis diac examination reveals a grade 3/6 decrescendo diastolic (D) Ventricular septal defect murmur heard at the left sternal border.

vt artery stenosis. The left anterior descending artery has non- G' Item 1 14 F obstructive lesions in the proximal segment. A 65-year-old woman is evaluated in the oIflce after several (l, visits to the emergency department for paroxysmal atrial Which of the following beneflts can the patient expect flbrillation and acute heart failure. Medications are apix- UI UI following coronary artery bypass grafting? aban, metoprolol, furosemide, and losartan. c, UI UI (A) Discontinuation of cardioprotective medications Vital signs are normal. Cardiopulmonary examination (B) Improvement in symptoms and the remainder of the physical examination are normal. Results of laboratory studies show a normal serum o t! (C) Increased survival thyroid-stimulating hormone level. (D) Reduced risk for myocardial infarction An ECG shows sinus rhythm with a heart rate of 58/min. An echocardiogram reveals a left ventricular ejec- tion fraction of 45%. Item 1 13 A 30 year-old man is seen in the offlce for slowly pro- Which of the following is the most appropriate gressive dyspnea that flrst appeared when walking rap- treatment? idly or uphill. He denies orthopnea, palpitations, or chest pain. He has no other medical problems and takes no (A) Atrioventricular node ablation with permanent pace- medications. maker implantation On physical examination, vital signs are normal. (B) Implantable cardioverter-deflbrillator placement Jugular venous distention is present. There is a left para- (C) Left atrial appendage occlusion sternal impulse. A grade 2/6 systolic murmur is heard (D) Rhythm control at the second left intercostal space, and a diastolic flow rumble is heard over the tricuspid valve. Fixed splitting of the S, is present. The remainder of the examination is normal. An ECG is shown. Chest radiograph reveals right heart Item 1 15 A 57 year old man is evaluated in the emergency department tr tbr sudden onset anterior chest pain. He has hypertension, enlargement, a prominent pulmonary artery, and increased hyperlipidemia, and coronary artery disease. Medications pulmonary vascularity. are hydrochlorothiazide. aspirin, amlodipine, olmesartan, labetalol, and atorvastatin. Which of the following is the most likely diagnosis? On physical examination, blood pressure is 172i 64 mm (A) Atrial septal defect IJg in the right arm and 135/63 mm I{g in the left arm, pulse (B) Bicuspid aortic valve with aortic regurgitation rate is 110/min, respiration rate is 24lmin, and oxygen sat- uration with the patient breathing ambient air is 96'X,. Car (C) Mitral stenosis diac examination reveals a grade 3/6 decrescendo diastolic (D) Ventricular septal defect murmur heard at the left sternal border. ITEM 1 13

vt artery stenosis. The left anterior descending artery has non- G' Item 1 14 F obstructive lesions in the proximal segment. A 65-year-old woman is evaluated in the oIflce after several (l, visits to the emergency department for paroxysmal atrial Which of the following beneflts can the patient expect flbrillation and acute heart failure. Medications are apix- UI UI following coronary artery bypass grafting? aban, metoprolol, furosemide, and losartan. c, UI UI (A) Discontinuation of cardioprotective medications Vital signs are normal. Cardiopulmonary examination (B) Improvement in symptoms and the remainder of the physical examination are normal. Results of laboratory studies show a normal serum o t! (C) Increased survival thyroid-stimulating hormone level. (D) Reduced risk for myocardial infarction An ECG shows sinus rhythm with a heart rate of 58/min. An echocardiogram reveals a left ventricular ejec- tion fraction of 45%. Item 1 13 A 30 year-old man is seen in the offlce for slowly pro- Which of the following is the most appropriate gressive dyspnea that flrst appeared when walking rap- treatment? idly or uphill. He denies orthopnea, palpitations, or chest pain. He has no other medical problems and takes no (A) Atrioventricular node ablation with permanent pace- medications. maker implantation On physical examination, vital signs are normal. (B) Implantable cardioverter-deflbrillator placement Jugular venous distention is present. There is a left para- (C) Left atrial appendage occlusion sternal impulse. A grade 2/6 systolic murmur is heard (D) Rhythm control at the second left intercostal space, and a diastolic flow rumble is heard over the tricuspid valve. Fixed splitting of the S, is present. The remainder of the examination is normal. An ECG is shown. Chest radiograph reveals right heart Item 1 15 A 57 year old man is evaluated in the emergency department tr tbr sudden onset anterior chest pain. He has hypertension, enlargement, a prominent pulmonary artery, and increased hyperlipidemia, and coronary artery disease. Medications pulmonary vascularity. are hydrochlorothiazide. aspirin, amlodipine, olmesartan, labetalol, and atorvastatin. Which of the following is the most likely diagnosis? On physical examination, blood pressure is 172i 64 mm (A) Atrial septal defect IJg in the right arm and 135/63 mm I{g in the left arm, pulse (B) Bicuspid aortic valve with aortic regurgitation rate is 110/min, respiration rate is 24lmin, and oxygen sat- uration with the patient breathing ambient air is 96'X,. Car (C) Mitral stenosis diac examination reveals a grade 3/6 decrescendo diastolic (D) Ventricular septal defect murmur heard at the left sternal border. ITEM 1 13 153

Self-Assessment Test t,l (D Item 118 D la tr tr CONT, A serum high-sensitivity cardiac troponin measure- ment is indeterminate. An ECG shows sinus tachycardia and lateral S'f A 78-year oldwoman is evaluated in follow up for a 3-month history of intermittent claudication, which is worse in the left .D u! UI segment clepressions. Chest radiograph is normal' leg than in the right. Her symptoms have become life limiting de"spite adherenie to a structured exercise program' Medical .D Which of the following is the most appropriate diagnostic history is sigfficant for type 2 diabetes mellitus and hyper test to perform in this Patient? tension. She has a 60-pack-year smoking history and quit (D (a l year ago. Medications are aspirin, metformin, canagliflozin, (A) Coronary artery catheterization cilostazol. atorvastatin, and olmesartan. (B) Invasive aortography On physical examination, vital signs are normal' Dor (C) Magnetic resonance angiography salis pedis and posterior tibialis pulses are faint bilaterally' (D) Transthoracic echocardiography and CT angiography The ankle brachial index is 0.82 on the right and 0'64 on the left. CT angiogram reveals dilluse calcified atherosclerotic

t,l (D Item 118 D la tr tr CONT, A serum high-sensitivity cardiac troponin measure- ment is indeterminate. An ECG shows sinus tachycardia and lateral S'f A 78-year oldwoman is evaluated in follow up for a 3-month history of intermittent claudication, which is worse in the left .D u! UI segment clepressions. Chest radiograph is normal' leg than in the right. Her symptoms have become life limiting de"spite adherenie to a structured exercise program' Medical .D Which of the following is the most appropriate diagnostic history is sigfficant for type 2 diabetes mellitus and hyper test to perform in this Patient? tension. She has a 60-pack-year smoking history and quit (D (a l year ago. Medications are aspirin, metformin, canagliflozin, (A) Coronary artery catheterization cilostazol. atorvastatin, and olmesartan. (B) Invasive aortography On physical examination, vital signs are normal' Dor (C) Magnetic resonance angiography salis pedis and posterior tibialis pulses are faint bilaterally' (D) Transthoracic echocardiography and CT angiography The ankle brachial index is 0.82 on the right and 0'64 on the left. CT angiogram reveals dilluse calcified atherosclerotic tr Item 1 16 A76 year old woman is evaluated in the emergency depart plaques in both iliac arteries, with a 30% stenosis on the right and an 80u1, stenosis in the left iliac artery. ment lor an episode ofnear syncope. She has also had progres sive dyspnea and nonproductive cough over a :l week period Which of the following is the most appropriate treatment? and an unintentional weight loss o14.1 kg (9 lb) over the past (A) Pentoxif,zlline 3 months. She reports no f'ever. She has a S0-pack-year history of cigarette smoking, but she stopped smoking 3 weeks ago. (B) Revascularization On physical examination, the patient is af'ebrile. Blood (C) Stop canagliflozin pressure is 132/60 mm Hg, with a fall in systolic pressure ol (D) Switch olmesartan to ramipril 24 mm tlg during inspiration. Pulse rate is 110/min and regu lar. Oxygen saturation is 90'X, with the patient breathing ambi ent air. BMI is 17. Jugular venous distention is present. I leart souncls are distant. Crackles are present at the lung bases. A chest radiograph shows a 6 cm right upper lobe mass Item 119 A 50 year-old woman is evaluated tbr a 3 month history tr of progressive chest pain. The pain is worse with ph1'sical and an enlarged cardiac silhouette. activity, radiates to the lett arm, and is associatecl with dia- phoresis.'lhe pain is relieved by rest. Which ofthe following is the most appropriate diagnostic test? On physical examination. blood pressure is 167,i98 mm (A) Cardiaccatheterization Hg. and pulse rate is 58rmin. Cardiac examination reveals an S., and no murmurs. (B) CT directed needle biopsy ECG shows sinus rhythm and left ventricular hyper- (C) Fiberopticbronchoscopy trophy,*,ith a strain pattern. (D) PET/CT (E) Transthoracic echocardiography Which ofthe following is the most appropriate diagnostie test? (A) Dobutamine echocardiography Item 117 (B) Dobutamine myocardial perfusion imaging (C) Exercise ECG A 57 year-old woman is seen during a routine follow-up visit for heart failure. She has a S-year history of ischemic (D) Exercise myocardial perfusion imaging cardiomyopathy with an ejection fraction of 38'/". She also has a 15 year history of type 2 diabetes mellitus and diabetic kidney disease. She has had no hospitalizations. Medica- Item 120 tions are aspirin, atorvastatin, valsartan sacubitril, metop A 49-year-old woman is evaluated for a 3 month history rolol succinate. and metfbrmin. of substernal chest heaviness that occurs when walking Physical examination, including vital signs, is unre- up a small hill near her home. The discomfort does not markable. radiate. Each episode lasts for approximately 5 minutes and Laboratory studies show an elevated B,type natriuretic improves as she continues walking. peptide level, a hemoglobin A,. level of 7.0"/,,, a serum cre, On physical examination, vital signs are normal. BMI atinine level of 1.5 mgi dL (132.6 pmol/L), and an estimated is 37. The remainder of the examination is unremarkable. glomerular flltration rate of 50 mL/min/1.73 m2. Resting ECG shows normal sinus rhythm without ischemic changes. Which of the following is the most appropriate additional treatment? Which of the following is the most likely diagnosis? (A) Dapagliflozin (A) Atypical angina (B) Glimepiride (B) Nonanginal chest pain (C) Liraglutide (C) Typical angina (D) Saxagliptin (D) Unstable angina

tr Item 1 16 A76 year old woman is evaluated in the emergency depart plaques in both iliac arteries, with a 30% stenosis on the right and an 80u1, stenosis in the left iliac artery. ment lor an episode ofnear syncope. She has also had progres sive dyspnea and nonproductive cough over a :l week period Which of the following is the most appropriate treatment? and an unintentional weight loss o14.1 kg (9 lb) over the past (A) Pentoxif,zlline 3 months. She reports no f'ever. She has a S0-pack-year history of cigarette smoking, but she stopped smoking 3 weeks ago. (B) Revascularization On physical examination, the patient is af'ebrile. Blood (C) Stop canagliflozin pressure is 132/60 mm Hg, with a fall in systolic pressure ol (D) Switch olmesartan to ramipril 24 mm tlg during inspiration. Pulse rate is 110/min and regu lar. Oxygen saturation is 90'X, with the patient breathing ambi ent air. BMI is 17. Jugular venous distention is present. I leart souncls are distant. Crackles are present at the lung bases. A chest radiograph shows a 6 cm right upper lobe mass Item 119 A 50 year-old woman is evaluated tbr a 3 month history tr of progressive chest pain. The pain is worse with ph1'sical and an enlarged cardiac silhouette. activity, radiates to the lett arm, and is associatecl with dia- phoresis.'lhe pain is relieved by rest. Which ofthe following is the most appropriate diagnostic test? On physical examination. blood pressure is 167,i98 mm (A) Cardiaccatheterization Hg. and pulse rate is 58rmin. Cardiac examination reveals an S., and no murmurs. (B) CT directed needle biopsy ECG shows sinus rhythm and left ventricular hyper- (C) Fiberopticbronchoscopy trophy,*,ith a strain pattern. (D) PET/CT (E) Transthoracic echocardiography Which ofthe following is the most appropriate diagnostie test? (A) Dobutamine echocardiography Item 117 (B) Dobutamine myocardial perfusion imaging (C) Exercise ECG A 57 year-old woman is seen during a routine follow-up visit for heart failure. She has a S-year history of ischemic (D) Exercise myocardial perfusion imaging cardiomyopathy with an ejection fraction of 38'/". She also has a 15 year history of type 2 diabetes mellitus and diabetic kidney disease. She has had no hospitalizations. Medica- Item 120 tions are aspirin, atorvastatin, valsartan sacubitril, metop A 49-year-old woman is evaluated for a 3 month history rolol succinate. and metfbrmin. of substernal chest heaviness that occurs when walking Physical examination, including vital signs, is unre- up a small hill near her home. The discomfort does not markable. radiate. Each episode lasts for approximately 5 minutes and Laboratory studies show an elevated B,type natriuretic improves as she continues walking. peptide level, a hemoglobin A,. level of 7.0"/,,, a serum cre, On physical examination, vital signs are normal. BMI atinine level of 1.5 mgi dL (132.6 pmol/L), and an estimated is 37. The remainder of the examination is unremarkable. glomerular flltration rate of 50 mL/min/1.73 m2. Resting ECG shows normal sinus rhythm without ischemic changes. Which of the following is the most appropriate additional treatment? Which of the following is the most likely diagnosis? (A) Dapagliflozin (A) Atypical angina (B) Glimepiride (B) Nonanginal chest pain (C) Liraglutide (C) Typical angina (D) Saxagliptin (D) Unstable angina 154