A 63-year-old woman has the sudden onset of 'knife-like' pain in the chest radiating to

the back. She has been previously healthy except for a history of poorly controlled
hypertension. She is transported to the hospital and on arrival she has a heart rate of
90/minute, respirations 20/minute, temperature 36.8°C, and blood pressure 150/100
mm Hg. No murmurs, rubs, or gallops are audible. A chest radiograph reveals a
widened mediastinum. Laboratory findings include a total serum creatine kinase of 55
U/L, creatinine 0.9 mg/dL, and glucose 123 mg/dL. Which of the following is the
most likely diagnosis?

A Fibrinous pericarditis

B Aortic dissection

C Infective endocarditis

D Dilated cardiomyopathy

E Myocardial infarction

A 45-year-old man was rushed to the hospital following the sudden onset of an
episode of crushing substernal chest pain. He receives advanced life support
measures. An EKG shows changes consistent with a large transmural anterolateral
area of infarction involving wall of the left ventricle. He develops cardiogenic shock.
Which of the following microscopic findings is most likely to be present in this area 4
days following the onset of his chest pain?

A Fibroblasts and collagen deposition

B Capillary proliferation and macrophages

C Myofiber necrosis with neutrophils

D Granulomatous inflammation

E Perivascular lymphocytic infiltrates

A 63-year-old woman has the sudden onset of 'knife-like' pain in the chest radiating to
the back. She has been previously healthy except for a history of poorly controlled
hypertension. She is transported to the hospital and on arrival she has a heart rate of
90/minute, respirations 20/minute, temperature 36.8°C, and blood pressure 150/100
mm Hg. No murmurs, rubs, or gallops are audible. A chest radiograph reveals a
widened mediastinum. Laboratory findings include a total serum creatine kinase of 55
U/L, creatinine 0.9 mg/dL, and glucose 123 mg/dL. Which of the following is the
most likely diagnosis?

A Fibrinous pericarditis

B Aortic dissection

C Infective endocarditis

D Dilated cardiomyopathy

E Myocardial infarction

A 45-year-old man was rushed to the hospital following the sudden onset of an
episode of crushing substernal chest pain. He receives advanced life support
measures. An EKG shows changes consistent with a large transmural anterolateral
area of infarction involving wall of the left ventricle. He develops cardiogenic shock.
Which of the following microscopic findings is most likely to be present in this area 4
days following the onset of his chest pain?

A Fibroblasts and collagen deposition

B Capillary proliferation and macrophages

C Myofiber necrosis with neutrophils

D Granulomatous inflammation

E Perivascular lymphocytic infiltrates

(C) CORRECT

A 45-year-old woman has had worsening shortness of breath for 3 years. She now has
to sleep sitting up on two pillows. She has had difficulty swallowing for the past year.
She has no history of chest pain. A month ago, she had a 'stroke' with resultant
inability to move her left arm. She is afebrile. A chest radiograph reveals a near-
normal left ventricular size with a prominent left atrial border. Which of the following
conditions is most likely to account for her findings?

A Essential hypertension

B Cardiomyopathy

C Mitral valve stenosis

D Aortic coarctation

E Patent foramen ovale

(C) CORRECT.

A 16-year-old healthy adolescent is involved in a schoolyard gang fight and is stabbed

in the chest with a knife in the left midclavicular line. He is taken to the emergency
department and on arrival his blood pressure is barely obtainable. His lungs are clear
to auscultation. His heart sounds are barely audible. Which of the following is the
most useful therapeutic approach for this boy?

A Coronary angioplasty

B Aortic repair

C Pericardiocentesis

D Antibiotic therapy

E Antiarrhythmic drugs

(C) CORRECT.

A 19-year-old woman has had increasing malaise for the past 5 months. On physical
examination she has a cardiac murmur characterized by a mid systolic click. An
echocardiogram demonstrates mitral insufficiency with upward displacement of one
leaflet. There is aortic root dilation to 4 cm. She has a dislocated right ocular
crystalline lens. A year later she dies suddenly and unexpectedly. The medical
examiner finds a prolapsed mitral valve with elongation, thinning, and rupture of
chordae tendineae. A mutation involving which of the following genes is most likely
to be present in this patient?

A Beta-myosin
B CFTR

C FGFR

D Fibrillin

E Spectrin

F Dystrophin

(D) CORRECT.

A 72-year-old woman has had no major illnesses throughout her life. She has had 3
syncopal episodes during the past 2 weeks. Over the past 2 days she has developed
shortness of breath and a cough with production of frothy white sputum. On physical
examination she is afebrile. Her blood pressure is 135/90 mm Hg. She has no
peripheral edema. A chest radiograph reveals a prominent left heart border in the
region of the left ventricle, but the other chambers do not appear to be prominent.
There is marked pulmonary edema. Laboratory studies show a total serum cholesterol
of 170 mg/dL. Which of the following is the most likely diagnosis?

A Acute rheumatic fever

B Mitral valve insufficiency

C Atherosclerotic aortic aneurysm

D Calcific aortic stenosis

E Infective endocarditis

(D) CORRECT

A 17-year-old girl is short in stature for her age. She has not yet shown any changes
of puberty. On physical examination her vital signs include T 37°C, RR 18/minute, P
75/minute, and BP 165/85 mm Hg. She has a continuous murmur heard over both the
front of the chest as well as her back. Her lower extremities are cool with diminished
pulses and poor capillary filling. She has a webbed neck. A chest radiograph reveals a
prominent left heart border, no edema or effusions, and rib notching. Which of the
following cardiovascular abnormalities is she most likely to have?
A Shortening and thickening of chordae tendineae of the mitral valve
B Narrowing of the aorta past the ductus arteriosus

C Supravalvular narrowing in the aortic root

D Lack of development of the spiral septum and partial absence of conus musculature

E Single large atrioventricular valve

(B) CORRECT.

A 65-year-old man has sudden onset of severe abdominal pain that has persisted for 3
hours. Physical examination reveals his temperature is 37°C, heart rate 110/minute,
respirations 25/minute, and blood pressure 145/100 mmHg. He has diminished pulses
in the lower extremities. There is a pulsatile abdominal mass. His serum creatine
kinase is not elevated. He has had fasting blood glucose measurements in the range of
140 to 180 mg/dL for over 20 years. Which of the following conditions is he most
likely to have?

A Superior mesenteric artery thrombosis

B Atherosclerotic aortic aneurysm

C Polyarteritis nodosa

D Acute coronary syndrome

E Monckeberg's medial calcific sclerosis

(B) CORRECT

A 49-year-old woman had atrial fibrillation that was poorly controlled, even with
amiodarone therapy. She suffered a 'stroke' and died. At autopsy, her 600 gm heart is
noted to have a mitral valve with partial fusion of the leaflets along with thickening
and shortening of the chordae tendineae. There is an enlarged left atrium filled with
mural thrombus. Which of the following underlying causes of death is she most likely
to have?

A Systemic lupus erythematosus

B Coronary atherosclerosis
C Marantic endocarditis

D Rheumatic heart disease

E Cardiac amyloidosis

(D) CORRECT

A 23-year-old woman has had worsening malaise along with a malar skin rash
persisting for 3 weeks. On physical examination, she has an audible friction rub on
auscultation of the chest, along with a faint systolic murmur. An echocardiogram
reveals small vegetations on the mitral valve and adjacent ventricular endocardium.
Laboratory studies show a positive serologic test for anti-Smith antibody, with a titer
of 1:2048. Which of the following is the most likely diagnosis?

A Polyarteritis nodosa

B Scleroderma, diffuse

C Systemic lupus erythematosus

D ANCA-associated granulomatous vasculitis

E Adenocarcinoma of the pancreas

(C) CORRECT.

A 27-year-old G2 P1 woman has a screening ultrasound performed at 18 weeks

gestation. The fetus is appropriate in size for 18 weeks. The fetal kidneys, liver, head,
and extremities appear normal. However, the fetus has a heart with a membranous
ventricular septal defect, overriding aorta, and marked pulmonic atresia. If the baby
were to be liveborn, which of the following characteristics on physical examination
would most likely result from these cardiac defects?

A Systemic hypertension

B Weak lower extremity pulses

C Clubbing of digits
D Telangiectasias

E Cyanosis

(E) CORRECT.

A 50-year-old man has the sudden onset of substernal chest pain. The pain persists for
the next three hours. He then becomes short of breath and diaphoretic. He goes to the
emergency department and on physical examination his vital signs include T 37°C, P
100/minute, RR 26/minute, and BP 130/90 mm Hg. A chest x-ray shows a slightly
enlarged heart and mild pulmonary edema. An EKG shows ST segment elevation in
anterior leads V1 - 6. Which of the following serum laboratory test findings is most
likely to be present in this man?

A Urea nitrogen of 110 mg/dL

B Sodium of 115 mmol/L

C ALT of 876 U/L

D Troponin I of 32 ng/mL

E HDL cholesterol of 55 mg/dL

(D) CORRECT

A 44-year-old woman dies as a consequence of a 'stroke'. At autopsy, she is found to

have a large right basal ganglia hemorrhage. She has an enlarged 550 gm heart with
predominantly left ventricular hypertrophy. Her kidneys are small, about 80 gm each,
with cortical scarring, and microscopically they demonstrate small renal arterioles that
have luminal narrowing from concentric intimal thickening. Which of the following is
the most likely condition associated with her findings?

A Autosomal dominant polycystic kidney disease

B Diabetes mellitus, type II

C Hypercholesterolemia

D Malignant hypertension

E Monckeberg's sclerosis
(D) CORRECT.

A 24-year-old woman with rheumatic heart disease becomes febrile. On physical

examination she has a systolic murmur. An echocardiogram shows vegetations of the
aortic valve cusps. A blood culture is positive for Staphylococcus epidermidis. She
receives a porcine bioprosthesis because of her desire to have children and not to take
anticoagulant medication. After ten years, she must have this prosthetic valve
replaced. Which of the following pathologic findings in the bioprosthesis has most
likely led to the need for replacement?

A Dehiscence

B Endocarditis

C Strut failure

D Calcification

E Thrombosis

(D) CORRECT.

A 25-year-old previously healthy woman collapses suddenly and unexpectedly.

Echocardiography shows global hypokinesis with increased left ventricular end
diastolic and systolic size, along with systolic left ventricular dysfunctionwith
decreased ejection fraction. An endomyocardial biopsy is obtained and
microscopically, the myocardium shows infiltration by small lymphocytes, with focal
myocyte necrosis. Which of the following infectious agents is most likely to have
caused these findings?

A Coxsackie B virus

B Candida albicans

C Aspergillus fumigatus

D Streptococcus, viridans group

E Staphylococcus aureus
F Cytomegalovirus

G Streptococcus, group A

CORRECT.

A 22-year-old man has had increasing malaise over the past 3 weeks. On physical
examination his vital signs show T 39.2°C, P 105/minute, RR 30/minute, and BP
80/40 mm Hg. On auscultation of his chest a loud systolic cardiac murmur is heard,
and his lungs have bibasilar crackles. Needle tracks are seen in his left antecubital
fossa. He has splinter hemorrhages noted on fingernails, as well as painful
erythematous nodules on palmar surfaces. A tender spleen tip is palpable. A chest
radiograph shows pronounced pulmonary edema. Which of the following laboratory
test findings is most likely to be present in this patient's peripheral blood?

A Creatine kinase-MB of 8% with a total CK 389 U/L

B Positive blood culture for Pseudomonas aeruginosa

C Total serum cholesterol of 374 mg/dL

D Blood urea nitrogen of 118 mg/dL

E Antinuclear antibody titer of 1:512

CORRECT.

A 2-year-old child has had failure to thrive for a year, becoming increasingly listless.
On examination she is found to have a soft, rumbling systolic ejection murmur. An
echocardiogram reveals a large membranous ventricular septal defect. Which of the
following complications is she most likely to experience as an adult 2 decades later if
this lesion remains untreated?

A Rib notching

B Mitral valve prolapse

C Pulmonary hypertension

D Myocardial infarction
E Cardiac tamponade

CORRECT

A 43-year-old woman has noted increasing dyspnea for the past 6 years. On
examination she is afebrile. Rales are auscultated in both lungs. A chest radiograph
shows an enlarged cardiac silhouette and bilateral pulmonary edema. Past history
reveals that, as a child she suffered recurrent bouts of pharyngitis with group A beta
hemolytic streptococcal infections. Which of the following cardiac valves are most
likely to be abnormal in this woman?

A Aortic and tricuspid

B Mitral and pulmonic

C Aortic and pulmonic

D Tricuspid and pulmonic

E Mitral and aortic

CORRECT.

A 26-year-old previously healthy woman has had worsening fatigue with dyspnea,
palpitations, and fever over the past week. On physical examination her vital signs
show T 38.9°C, P 104/minute, RR 30/minute, and BP 95/65 mm Hg. Her heart rate is
slightly irregular. An ECG shows diffuse ST-T segment changes. A chest x-ray shows
mild cardiomegaly. An echocardiogram shows slight mitral and tricuspid
regurgitation but no valvular vegetations. Laboratory studies show a troponin I of 12
ng/mL. She recovers over the next two weeks with no apparent sequelae. Which of
the following laboratory test findings best explains the underlying etiology for these
events?

A Anti-streptolysin O titer of 1:512

B Total serum cholesterol of 537 mg/dL

C Echovirus serologic titer of 1:160

D Blood culture positive for Streptococcus, viridans group

E ANCA titer of 1:80

(C) CORRECT. Findi

A 45-year-old man has had no major medical problems throughout his life, except for
arthritis pain involving all extremities for the past 5 years. He has had worsening
orthopnea and pedal edema in the past 6 months. There is no chest pain. On
examination he is afebrile. A chest radiograph shows cardiomegaly with prominent
left and right heart borders, along with pulmonary edema. Laboratory studies show
serum sodium 139 mmol/L, potassium 4.3 mmol/L, chloride 99 mmol/L, CO2 25
mmol/L, urea nitrogen 18 mg/dL, creatinine 1.3 mg/dL, and glucose 167 mg/dL.
Which of the following additional laboratory test findings is he most likely to have?

A Spherocytes on his peripheral blood smear

B Hemoglobin of 10.7 g/dL with MCV of 72 fL

C Erythrocyte sedimentation rate of 79 mm/Hr

D Anti-centromere antibody titer of 1:320

E Serum ferritin of 800 ng/mL

E CORRECT..

A 37-year-old previously healthy man has had worsening dyspnea along with
peripheral edema for the past two years. On physical examination he has diffuse
crackles auscultated over both lungs. A chest radiograph shows that the heart nearly
fills the chest. A chest CT scan demonstrates a 10 cm mass involving the right
ventricle that appears to have areas of hemorrhage and necrosis within it. Which of
the following neoplasms is this man most likely to have?

A Rhabdomyosarcoma
B Mesothelioma

C Myxoma

D Angiosarcoma

E Papillary fibroelastoma

F Kaposi sarcoma

G Rhabdomyoma

(D) CORRECT..

A 20-year-old primigravida delivers a term baby girl following an uncomplicated

pregnancy. No anomalies are noted at the time of birth. Five weeks later, the mother
brings the baby to the clinic because she has difficulty breathing and occasionally
turns pale. On physical examination a pansystolic murmur is audible. Which of the
following congenital cardiac anomalies is most likely to be present in this infant?

A Hypertrophic subaortic stenosis

B Hypoplastic left heart syndrome

C Coarctation of the aorta

D Ventricular septal defect

E Bicuspid aortic valve

(D) CORRECT.

An epidemiologic study of eating habits is performed. Dietary patterns of adult

patients are recorded and compared to risk for cardiovascular diseases. It is observed
that persons who eat bacon for breakfast are more likely to have cardiovascular
disease than persons who eat oat bran cereal. Which of the following conditions is the
'bacon' group most likely to have?

A Mitral annulus calcification

B Ventricular aneurysm
C Left atrial dilation

D Thoracic aortic aneurysm

E Aortic valve stenosis

(B) CORRECT

A 78-year-old woman has had increasing dyspnea for the past 5 years. On
examination her blood pressure is 130/85 mm Hg. Her BMI is 35. Rales are
auscultated in both lungs. Her B-type natriuretic peptide, C-reative protein and LDL
cholesterol are elevated. A chest x-ray shows infiltrates in all lung fields and an
enlarged heart. Echocardiography shows decreased ejection fraction with segmental
wall motion abnormalities. Which of the following forms of cardiomyopathy is she
most likely to have?

A Alcoholic

B Arrhthmogenic

C Hypertrophic

D Infiltrative

E Ischemic

(E) CORRECT.

A 53-year-old man has had malaise for the past 3 months. On physical examination he
is afebrile. On auscultation of the chest, heart sounds are distant and there is a friction
rub. An echocardiogram shows a pericardial fluid collection. A pericardiocentesis
yields 10 mL of bloody fluid. Which of the following conditions is most likely to give
rise to these findings?

A Autoimmune disease

B Chronic renal failure

C Rheumatic fever

D Metastatic carcinoma

E Acute myocardial infarction

(D) CORRECT