Maintenance of Certification in Cardiology

Preparing for the American Board of Internal Medicine Maintenance of Certification

The following questions can assist candidates prepare for the Maintenance of Certification Exam in Cardiovascular Disease. Feedback regarding these questions is welcomed and can be sent to editor@cardiology-review.com.

All of the following conditions may cause cardiac arrest, EXCEPT:

1.

a) Pulseless electrical activity

b) Ventricular fibrillation

c) Ventricular tachycardia

d) Asystole

e) Ventricular bigeminy

Which of the following statements about atrial fibrillation (AF) is FALSE?

2.

a) The prevalence of AF ranges from 0.1% among adults <55 years of age to 9% in those ≥80 years of age.

b) The most common reasons for underuse of anticoagulant agents are physician-based, including fear of hemorrhage, insufficient time to talk with the patient, or a lack outpatient-monitoring facilities.

c) Patients with AF at greatest risk of recurrent stroke are those who have had a stroke or transient ischemic attack.

d) In elderly women, AF is the single most frequent precursor of ischemic stroke.

e) Up to 15% of all strokes occur in patients with AF, and the proportion increases to >35% after age 75.

3. Which is the most sensitive screening test for prediabetes?

a) Fasting blood glucose

b) 1-hour glucose tolerance

c) 2-hour glucose tolerance

d) Random blood glucose

4.

You see an 82-year-old man who suddenly developed slurred speech and left-sided weakness. On evaluation 1 hour after symptom onset, his blood pressure is 234/114 mm Hg, and neurologic examination shows left facial droop, dysarthria, and moderate left hemiparesis. Results of laboratory studies, including complete blood cell count, plasma glucose, and prothrombin and partial thromboplastin times, are normal. Head computed tomography is normal. He is given 10 mg of intravenous labetalol HCl (Trandate, Normodyne), and his blood pressure decreases to 230/108 mm Hg. What is the most appropriate next step?

a) Intravenous recombinant-tissue plasminogen activator (rt-PA)

b) Aspirin

c) Intravenous nitroprusside (Nitropress)

d) No additional treatment for hypertension

e) Abciximab (ReoPro)

5.

According to the most recent guidelines of the American Heart Association, antibiotic prophylaxis for endocarditis is no longer recommended for patients with which condition?

a) A prosthetic aortic or mitral valve

b) A history of endocarditis

c) Congenital heart disease that has not been repaired

d) A heart transplant and valvulopathy

e) Patients with mitral valve prolapse

6.

Which of the following statements about hypertension in the elderly is FALSE?

a) The risk of cardiovascular adverse events is linear and doubled by a 10 mm Hg rise of either the systolic or diastolic component of blood pressure.

b) Isolated systolic hypertension is the most common form of hypertension in the elderly.

c) Hypertension in patients 65 years of age and older is considered a blood pressure of ≥140/90 mm Hg.

d) After age 55, diastolic blood pressure usually remains normal or is reduced.

Answers

1: e

Cardiac arrest can occur as a result of ventricular fibrillation (VF), pulseless ventricular tachycardia (pVT), pulseless electrical activity (PEA, previously called electromechanical dissociation [EMD]), or asystole. VF and pVT appear to be responsible for 25% to 35% of all out-of-hospital episodes of cardiac arrest, although estimates vary significantly from study to study. PEA now accounts for as many as 25% of all cases of cardiac arrest, and this proportion is increasing. In ventricular bigeminy, a ventricular premature beat follows each normal beat, and this rhythm alone is not associated with hemodynamic collapse.

Source

Smith L. Practice guidelines: diagnosis and management of chronic heart failure in adults. Am Fam Physician.

2007;75:742. http://www.aafp.org/afp/20070301/practice.html. Accessed September 16, 2008.

2: b

The most common reasons for underuse of anticoagulant agents include patient variables, such as advanced age, perceived risks of falls, history of bleeding, assumptions about patient or family preference, and concerns about compliance. The epidemiologic importance of atrial fibrillation (AF) is substantial. The incidence of AF has reached epidemic proportions in the elderly, and this trend is likely to continue. About 15% of all strokes occur in patients with AF, and this proportion increases greatly with age. The most important risk factors for stroke are a history of stroke or transient ischemic attack (the most powerful predictor of stroke risk), age, history of high blood pressure or systolic blood pressure reading higher than 160 mm Hg, and diabetes mellitus. These have all remained strong and consistent independent risk factors for stroke. Maintaining optimal blood pressure is an important adjunct in reducing the risk of intracerebral bleeding, the most serious consequence of anticoagulation. For this reason, angiotensin-converting enzyme inhibitors and diuretics are emerging as important therapies in stroke reduction. Firmly established risk factors for intracerebral hemorrhage in patients on warfarin include age older than 75 years, hypertension, cerebrovascular disease, and international normalized ratio values higher than 3.5.

Source

Geriatrics

Strong SH, Halperin JL. Confronting atrial fibrillation in the elderly: stroke risk stratification and emerging antithrombotic therapies. . 2007;62(3):22-27.

3: c

Prediabetes is the clinical state in which blood glucose levels are elevated but are not high enough to satisfy the diagnostic criteria for diabetes. Impaired fasting glucose and impaired glucose tolerance have been referred to as prediabetes. The 2-hour oral glucose tolerance test is recommended for prediabetes screening because it is more sensitive than the fasting blood glucose test. Although fasting blood glucose is more practical and convenient for screening, it may miss some patients with glucose intolerance.

Source

Endocr Pract

American Association of Clinical Endocrinologists Diabetes Mellitus Clinical Practice Guidelines Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. . 2007;13(suppl 1):1-68.

4: c

This patient has had a moderate ischemic stroke and was seen within the critical 3-hour window for using recombinant-tissue plasminogen activator (rt-PA, alteplase [Activase]). His advanced age is of concern, but this alone does not increase the risk of intracranial hemorrhage enough to withhold intervention in an older patient who is otherwise a candidate for thrombolysis.

Severe hypertension, however, is a risk factor for intracerebral hemorrhage in patients receiving rt-PA, and his blood pressure elevation is a contraindication for thrombolytic therapy. He should be given a short-acting parenteral antihypertensive agent to lower his blood pressure to below 185/110 mm Hg. Intravenous

nitroprusside (Nitropress) or nicardipine HCl (Cardene) or an increased dose of labetalol HCl (Trandate, Normodyne) is the most appropriate management for this patient to decrease blood pressure before re-evaluation for thrombolysis.

For patients with acute ischemic stroke in whom thrombolysis is contraindicated, hypertension is generally not treated in the acute setting if there is no evidence of noncerebral hypertensive organ damage (acute myocardial infarction, aortic dissection, pulmonary edema, or renal failure) or if the patient’s blood pressure is above 220 mm Hg systolic or above 120 mm Hg diastolic.

Antiplatelet therapy with aspirin, 160 mg to 300 mg once a day, started within 48 hours of a presumed ischemic stroke, significantly reduces the risk of early recurrence without a major risk of early hemorrhagic complications and improves long-term outcome. Although prior aspirin use is not a contraindication for rt-PA, it should not be given in the acute setting until thrombolysis is ruled out. Because of a high rate of intracranial hemorrhage in an efficacy trial, abciximab (ReoPro) should not be used.

Sources

Neurocrit Care

Neurocrit Care

Rose JC, Mayer SA. Optimizing blood pressure in neurological emergencies [published correction appears in . 2006;4(1):98]. . 2004;1(3):287-99.

JAMA

Caplan LR. Treatment of acute stroke: still struggling. . 2004;292(15):1883-1885.

Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic

Chest

stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. . 2004;126(3 suppl):483S-512S.

5: e

In 2007, the American Heart Association made major revisions to their guidelines for the prevention of infective endocarditis (IE). The recommendation for antimicrobial prophylaxis for dental and other procedures is now limited to only those patients with cardiac conditions with the highest risk of adverse outcomes from IE. The prior guidelines had recommended prophylaxis for patients at moderate to high risk of IE, a much larger population. Highest-risk patients include: recipients of prosthetic heart valves; individuals with a history of IE; patients with unrepaired cyanotic congenital heart disease, including those who have received palliative shunts and conduits; patients who have had a congenital heart defect completely repaired within the previous 6 months using prosthetic material or devices (placed by surgery or by catheter intervention); patients with repaired congenital heart disease with residual defects at the site or adjacent to the site of the prosthetic device; and those with cardiac “valvulopathy” in a transplanted heart, defined as documentation of substantial leaflet pathology and regurgitation.

Source

Wilson W, Taubert KA, Gewitz M, et al; American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young; Council on Clinical Cardiology; Council on Cardiovascular Surgery and Anesthesia; Quality of Care

J Am Dent Assoc

and Outcomes Research Interdisciplinary Working Group; American Dental Association. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. . 2007;138(6):739-745, 747-760.

6: a

Hypertension is defined as a blood pressure ≥140/90 mmg Hg, and this establishes the prevalence of the disorder as 65% in persons 65 years of age and older. The most common form of hypertension in the elderly is isolated systolic hypertension. The risk of cardiovascular adverse events is linear and doubles with increments of 20 mm Hg in the systolic component or only 10 mm Hg in the diastolic component. The relative risk of death was 1.28 (not quite double) for a 10 mm Hg increase in systolic blood pressure, but still a significant increase. Diastolic blood pressure usually remains normal or drops in response to aging, while systolic blood pressure will usually rise. This phenomenon results in a widening of the pulse pressure.

Source

Resident & Staff Physician

Rehman SU, Hutchison FN, Basile JN. Practical approach to the management of hypertension in the elderly. . 2007;53(10):5-11.