A 62-year-old man with smoking, hypertension, and diabetes mellitus complains of shortness of breath on exertion. He gets short of breath walking up a flight of stairs. There is no chest pain. On physical examination, heart rate 72 bpm, regular; blood pressure 148/90 mmHg, body mass index (BMI) 24. Jugular venous pressure (JVP) and heart sounds are normal. The electrocardiogram shows normal sinus rhythm. The echocardiogram shows mild left ventricular (LV) hypertrophy, normal wall motion, normal valvular function, mitral E/A velocity ratio of 0.7, E/E′ ratio of 7, pulmonary artery (PA) systolic pressure of 50 mmHg. What is the most productive next step?

1. Add calcium channel blocker (CCB) as a lusiotropic agent as it may reduce PA pressure
   
2. Computed tomography (CT) pulmonary angiography to rule out pulmonary embolism
   
3. Right heart catheterization (RHC) to evaluate for pulmonary vascular resistance and its response to O₂ and pulmonary vasodilators
   
4. Diuresis to reduce left atrial (LA) pressure as this may reduce PA pressure

Which of the following agents are shown to improve survival in heart failure with reduced ejection fraction (HFrEF)?

1. Carvedilol and metoprolol succinate
   
2. Angiotensin-converting-enzyme inhibitor (ACEI)
   
3. Spironolactone
   
4. All of the above
   
5. None of the above

Which of the following agents are shown to improve survival in heart failure with preserved ejection fraction (HFpEF)?

1. Carvedilol and metoprolol succinate
   
2. ACEI
   
3. Spironolactone
   
4. All of the above
   
5. None of the above

A 62-year-old asymptomatic hypertensive had an echocardiogram for a murmur. The rest of the physical examination was normal. Echocardiogram showed normal LV wall thickness and wall motion with ejection fraction (EF) of 65%. Valves were normal. Mitral E/A velocity ratio was 0.7. What does the patient have?

1. Stage A heart failure (HF)
   
2. Stage B HF
   
3. HFpEF
   
4. None of the above

Diagnosis of HF by Framingham criteria requires which of the following?

1. Two major or one major and two minor criteria
   
2. Four major criteria
   
3. Two major criteria and raised serum brain natriuretic peptide (BNP)
   
4. None of the above

The major Framingham criteria for HF include:

1. S3
   
2. Paroxysmal nocturnal dyspnea
   
3. Basal rales
   
4. All of the above

The minor Framingham criteria for HF include which of the following?

1. Shortness of breath
   
2. Edema
   
3. Nocturnal cough
   
4. All of the above

Which of the following are class I indications for echocardiography, based on American College of Cardiology Foundation and imaging societies’ appropriateness criteria in subjects with HF?

1. Clinical HF
   
2. Family history of cardiomyopathy, but no clinical HF
   
3. Cardiotoxic chemotherapy
   
4. All of the above

In which patients with HFrEF is coronary angiography most appropriate and clearly indicated?

1. A 52-year-old patient with EF of 30%, diabetes, and angina on walking one block
   
2. A 63-year-old man with prior ST elevation myocardial infarction, scarred left anterior descending artery area on nuclear testing, no reversible ischemia, EF of 30%, but short of breath on exertion
   
3. A 22-year-old patient with HF, EF of 10%, severely dilated left ventricle
   
4. None of the above

Compared with atrial myocyte, ventricular myocyte is which of the following?

1. Longer
   
2. Broader
   
3. Has more T tubules
   
4. All of the above
   
5. None of the above.

Which of the following has absent T tubules?

1. Ventricular myocyte
   
2. Atrial myocyte
   
3. Purkinje cells
   
4. None of the above

Which of the following have the most abundant gap junctions?

1. Ventricular myocyte
   
2. Atrial myocyte
   
3. Purkinje cells
   
4. None of the above

What is the increase in myocardial contractile force with increase in preload called?

1. Frank–Starling phenomenon
   
2. Anrep phenomenon
   
3. Bowditch phenomenon
   
4. None of the above.

What is the increase in myocardial contractile force with acute increase in afterload called?

1. Frank–Starling phenomenon
   
2. Anrep phenomenon
   
3. Bowditch phenomenon
   
4. None of the above.

What is the increase in myocardial contractile force with increase in heart rate called?

1. Frank–Starling phenomenon
   
2. Anrep phenomenon
   
3. Bowditch phenomenon
   
4. None of the above.

An increase in LV end-systolic size would increase which of the following?

1. LV preload
   
2. LV afterload
   
3. None
   
4. Both

What would an acute increase in afterload result in?

1. Reduction in LV EF
   
2. Increase in LV end-systolic volume
   
3. Increased LV contractility
   
4. All of the above.

Which of the following does the LV EF depend upon?

1. LV preload
   
2. LV afterload
   
3. LV contractility
   
4. All of the above

Which of the following factors affect LV diastolic function?

1. LV relaxation process
   
2. Modulus of chamber stiffness
   
3. LV recoil
   
4. All of the above

Submassive acute pulmonary embolism may cause all of the following except which option?

1. Increase in intrapericardial pressure
   
2. Increase in LV end-diastolic pressure
   
3. Reduced LV filling
   
4. Increase in stroke volume

Which of the following is not acceptable as a donor heart for heart transplant?

1. Bicuspid aortic valve
   
2. History of meth use with normal EF and absence of LV hypertrophy
   
3. Atrial septal defect with normal right ventricle function
   
4. History of alcohol abuse and EF of 35% on pressors

What is your recommendation for a donor heart that is normal except for 3+ functional tricuspid regurgitation (TR)?

1. Reject the heart
   
2. Assign the heart to alternate list
   
3. Do DeVega annuloplasty on bench and use the heart
   
4. Do tricuspid valve replacement and use the heart

What are the likely outcomes after heart transplant in a patient with preoperative moderate PH and increased pulmonary vascular resistance?

1. Right ventricular (RV) dilation and failure
   
2. Tricuspid regurgitation
   
3. Low output state
   
4. None of the above
   
5. Options A–C

Which of the following reduces serum levels of cyclosporine, tacrolimus, and sirolimus?

1. Phenytoin
   
2. Phenobarbital
   
3. Rifampicin
   
4. All of the above

Which of the following increases serum levels of cyclosporine, tacrolimus, and sirolimus?

1. Erythromycin
   
2. Ketoconazole and fluconazole
   
3. Diltiazem and verapamil
   
4. Amiodarone
   
5. All of the above

Which of the following are potential side effects of tacrolimus?

1. Diabetes mellitus
   
2. Tremor
   
3. Anemia
   
4. All of the above
   
5. None of the above

Potential side effects of cyclosporine include which of the following?

1. Hypertension
   
2. Hypertriglyceridemia
   
3. Hypercholesterolemia
   
4. Increase in creatinine
   
5. All of the above

Which of the following are treatment options for antibody-mediated graft rejection?

1. High dose corticosteroid
   
2. Intravenous (IV) immunoglobulin
   
3. Daily plasmapheresis
   
4. IV rituximab
   
5. All of the above.

Which of the following drugs may retard cardiac allograft vasculopathy?

1. Sirolimus
   
2. Everolimus
   
3. Statins
   
4. Mycophenolate mofetil
   
5. All of the above.

In an adult patient with heart transplant beyond 6 months, which of the following surveillance regimens for rejection is appropriate?

1. Biannual endomyocardial biopsy for the first 5 years
   
2. Biannual endomyocardial biopsy for indefinite period of time
   
3. Echocardiography in place of biopsy
   
4. Cardiac magnetic resonance imaging with delayed enhancement in place of biopsy
   
5. All of the above

Which of the following are not acceptable practices for cardiac allograft surveillance?

1. Monitoring of serum BNP trends
   
2. Monitoring of troponin I and C-reactive protein
   
3. Echocardiography in place of biopsy
   
4. Cardiac magnetic resonance imaging with delayed enhancement in place of biopsy
   
5. All of the above

In a patient with heart transplant, pregnancy should be discouraged under which of the following circumstances?

1. Within a year of transplant
   
2. Evidence of LV dysfunction
   
3. Evidence of coronary vasculopathy
   
4. All of the above
   
5. None of the above.

Which of the following statements are true in a heart transplant patient who gets pregnant?

1. Discontinue all antirejections medications in the first trimester because of teratogenicity
   
2. Discontinue all antirejections medications throughout pregnancy because of fetal growth retardation
   
3. Continue corticosteroids and calcineurin inhibitors (cyclosporine or tacrolimus)
   
4. Continue corticosteroids, tacrolimus and mycophenolate mofetil

Which of the following statements are true regarding coronary angiography after heart transplant?

1. Reasonable to perform coronary angiogram at 6 months after heart transplant
   
2. Reasonable to perform coronary angiogram at 5 years after heart transplant and then annually
   
3. Both A and B
   
4. Neither A nor B

Which of the following patients are reasonable candidates to evaluate for heart transplant?

1. Male, 60 years, EF of 10%, class IV HF, inotrope dependent
   
2. Female, 57 years, EF 35%, class IV angina, poor targets for percutaneous coronary intervention or coronary artery bypass grafting and refractory to medical therapy
   
3. Male, 67 years, class III symptoms, EF 20%, V_O2 max 8 mL/(kg min)
   
4. All of the above
   
5. None of the above.

Which of the following are absolute contraindications for heart transplant?

1. Prostatic carcinoma, status post treatment with persistently elevated prostate-specific antigen
   
2. AIDS with opportunistic infections
   
3. Fixed PH with PA systolic pressure >60 mmHg or pulmonary vascular resistance >6 Wood units or transpulmonary gradient >15 mmHg
   
4. All of the above.
   
5. None of the above

Which of the following patients are undesirable candidates for heart transplant for class IV HF?

1. Male, 75 years, with HFrEF and EF 10%
   
2. Patient on hemodialysis for heart transplant alone
   
3. Living alone with no social support
   
4. BMI >35 kg/m²
   
5. All of the above

Which of the following statements are true regarding an implantable left ventricular assist device (LVAD)?

1. In patients with severe class IV HFrEF ineligible for heart transplant, it prolongs survival
   
2. It may be used as bridge to transplant
   
3. It may be used as bridge to recovery
   
4. It may be used as destination therapy
   
5. All are correct.

In a patient considered for LVAD, which of the following findings may increase associated risk?

1. Highly trabeculated left ventricle
   
2. LV apical thrombus
   
3. LV end diastolic diameter <63 mm
   
4. All of the above

Which of the following are red-flag findings in patients undergoing LVAD?

1. LA appendage thrombus
   
2. Severe RV dysfunction
   
3. Patent foramen ovale (PFO)
   
4. Ventricular septal defect (VSD)
   
5. All of the above.

Which of the following valvular lesions may be problematic in patients undergoing LVAD?

1. Moderate or severe aortic regurgitation (AR)
   
2. Moderate or severe mitral stenosis
   
3. Moderate or severe TR
   
4. All of the above

Which of the following valve lesions may not significantly impede LVAD function?

1. Mitral regurgitation
   
2. Aortic stenosis
   
3. Pulmonary regurgitation
   
4. All of the above.

Which of the following prosthetic valves may need to be explanted before LAVD implant?

1. Mechanical aortic valve
   
2. Bioprosthetic aortic valve
   
3. Normally functioning mechanical mitral valve
   
4. Mechanical mitral valve with 3+ mitral regurgitation (MR)
   
5. All of the above.

Which of the following are preferred surgical options to be included for severe AR before LVAD implant?

1. Bioprosthesis
   
2. Complete sewing and closure
   
3. Park stitch (central suture)
   
4. All of the above
   
5. None of the above

What is sudden desaturation soon after LVAD implant likely due to?

1. Unmasked PFO
   
2. AR
   
3. Unmasked RV dysfunction
   
4. Pulmonary embolism

Which of the following options is true about AR quantitation after LVAD?

1. Should be upgraded by one grade based on traditional criteria
   
2. Should be downgraded by one grade
   
3. Should be based on aortic flow reversal in diastole
   
4. None of the above
   
5. All of the above

What is a recommended approach if leftward septal shift, severe RV dysfunction, and severe TR occur soon after LVAD implant even at low speed?

1. Reduce the LV cannula size
   
2. Perform tricuspid valve repair
   
3. Infuse fluid
   
4. Change to biventricular mechanical circulatory support

Which of the following echo findings indicate normal LVAD function?

1. Inflow (LV) cannula velocity of <1.5 m/s without turbulence
   
2. Ouflow (aortic) cannula velocity of <2.0 m/s without turbulence
   
3. Intermittent opening of aortic valve
   
4. Ventricular septum in the middle
   
5. All of the above

What may signs of LVAD malfunction include?

1. Diastolic flow reversal in inflow and outflow cannula with pump arrest
   
2. Reduced response to increase in pump speed
   
3. LV dilation
   
4. Low velocities in cannula
   
5. All of the above

What may persistent aortic valve closure in a patient with LVAD result in?

1. Aortic root thrombus
   
2. AR
   
3. Both A and B
   
4. Neither A nor B

What should one not do when aortic root thrombus is seen in a patient with LVAD?

1. Reduce pump speed
   
2. Increase pump speed
   
3. Neither

What might signs of an LV suction event include?

1. LV end diastolic diameter <3 cm
   
2. Obstruction to inflow cannula
   
3. Leftward septal shit
   
4. Increase in TR
   
5. All of the above.
   
6. None of the above.

A patient with an LVAD presents with heart failure. An echocardiogram shows an increase in LV size and greater opening of aortic valve with each beat from 90 to 200 ms. What is the most likely cause?

1. Thrombosis of the LVAD
   
2. Hypertension
   
3. Pulmonary embolism
   
4. None of the above

With increase in pump speed, which of the following may occur?

1. Reduced opening of aortic valve
   
2. A diminution of systolic velocity and an increase in diastolic velocity in the aortic cannula
   
3. A diminution in LV size
   
4. Septal shit to left
   
5. All of the above

Which statin has least interaction with immune suppressants?

1. Simvastatin
   
2. Pravastatin
   
3. Atorvastatin
   
4. Rosuvastatin

Which immunosuppressant may increase serum creatinine level?

1. Sirolimus
   
2. Cyclosporine
   
3. Mycophenolate mofetil
   
4. Corticosteroid

A 45-year-old man with heart transplant performed 6 years ago is admitted with shortness of breath and fever. He is on prednisone, tacrolimus, mycophenolate mofetil, diltiazem, and pravastatin Chest X-ray is suggestive of pneumonia. The echocardiogram showed normal LV function, wall thickness, and filling pressures. The white cell count is 16 000, and serum creatinine is 3.2 mg/dL. In addition to treating with appropriate antibiotics, what would you do?

1. Start dobutamine infusion
   
2. Discontinue tacrolimus
   
3. Treat with IV immunoglobulin
   
4. Perform plasmapheresis

In a patient with systolic heart failure on optimal doses of carvedilol and spironolactone, which drug is likely to produce maximum mortality and HF admission benefit?

1. ACEI
   
2. Angiotensin receptor blocker
   
3. Neprilysin inhibitor
   
4. Diuretic

In Questions 11.59–11.66, match the question’s clinical scenario to the indicated risk of PH, if any, and to the type of pulmonary arterial hypertension (PAH) based on the current classification system. See Box 11.2 on the classification of pulmonary hypertension at the end of this chapter. Each option may apply to more than one clinical situation or none at all.

A 62-year-old woman, with a history of hypertension and obesity (current BMI 31), presents with dyspnea. On echo there is normal LV and valvular function, mitral E/e′ ratio is 6, and PA systolic pressure is 60 mmHg. She has used the appetite-suppressant drug fen-phen for 2 years in the past. Based on the current classification system, which of the following options best describes this patient’s condition?

1. No PH
   
2. Group 1 PH
   
3. Group 2 PH
   
4. Group 3 PH
   
5. Group 4 PH
   
6. Group 5 PH

A 27-year-old woman has idiopathic PH. Based on the current classification system, which of the following options best describes this patient’s condition?

1. No PH
   
2. Group 1 PH
   
3. Group 2 PH
   
4. Group 3 PH
   
5. Group 4 PH
   
6. Group 5 PH