Cardiac rehabilitation — MCQs

10 questions

A 45-year-old man presents for his annual checkup. The patient has a past medical history of diabetes mellitus (DM) type 2 that is well-controlled with diet. In addition, he was admitted to this hospital 1-year ago for a myocardial infarction (MI). The patient reports a 40-pack-year smoking history. However, after his MI, his doctors informed him about how detrimental smoking was to his heart condition. Since then, he has made efforts to cut down and now, for the past seven months, has stopped smoking. He says he used to use smoking as a means of dealing with his work and family stresses. He now attends wellness sessions at work and meditates early every morning before the family wakes up. Which of the following stages of the transtheoretical model is this patient most likely in?

A 60-year-old male engineer who complains of shortness of breath when walking a few blocks undergoes a cardiac stress test because of concern for coronary artery disease. During the test he asks his cardiologist about what variables are usually used to quantify the functioning of the heart. He learns that one of these variables is stroke volume. Which of the following scenarios would be most likely to lead to a decrease in stroke volume?

A 57-year-old otherwise healthy male presents to his primary care physician for a check-up. He has no complaints. His blood pressure at the previous visit was 160/95. The patient did not wish to be on any medications and at the time attempted to manage his blood pressure with diet and exercise. On repeat measurement of blood pressure today, the reading is 163/92. His physician decides to prescribe a medication which the patient agrees to take. The patient calls his physician 6 days later complaining of a persistent cough, but otherwise states that his BP was measured as 145/85 at a local pharmacy. Which of the following is a contraindication to this medication?

A 56-year-old woman comes to the physician for follow-up after a measurement of elevated blood pressure at her last visit three months ago. She works as a high school teacher at a local school. She says that she mostly eats cafeteria food and take-out. She denies any regular physical activity. She does not smoke or use any recreational drugs. She drinks 2 to 3 glasses of wine per day. She has hypercholesterolemia for which she takes atorvastatin. Her height is 165 cm (5 ft 5 in), weight is 82 kg (181 lb), and BMI is 30.1 kg/m2. Her pulse is 67/min, respirations are 18/min, and blood pressure is 152/87 mm Hg on the right arm and 155/92 mm Hg on the left arm. She would like to try lifestyle modifications to improve her blood pressure before considering pharmacologic therapy. Which of the following lifestyle modifications is most likely to result in the greatest reduction of this patient's systolic blood pressure?

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

A 62-year-old man with a past medical history of previous myocardial infarction, angina, hypertension, hyperlipidemia, diabetes mellitus, peripheral vascular disease, and below knee amputation has developed new chest pain. His medication includes insulin, hydrochlorothiazide, lisinopril, metoprolol, daily aspirin, atorvastatin, and nitroglycerin as needed. His vitals include: blood pressure 135/87 mm Hg, pulse 52/min, and respirations 17/min. Coronary arteriography shows a reduced ejection fraction, a 65% stenosis of the left anterior descending artery, and a 75% stenosis of the left circumflex artery. Which of the following is the recommended treatment for the patient?

An 18-year-old boy is brought to the emergency department by his parents because he suddenly collapsed while playing football. His parents mention that he had complained of dizziness while playing before, but never fainted in the middle of a game. On physical examination, the blood pressure is 130/90 mm Hg, the respirations are 15/min, and the pulse is 110/min. The chest is clear, but a systolic ejection murmur is present. The remainder of the examination revealed no significant findings. An electrocardiogram is ordered, along with an echocardiogram. He is diagnosed with hypertrophic cardiomyopathy and the physician lists all the precautions he must follow. Which of the following drugs will be on the list of contraindicated substances?

An 80-year-old man presents to the emergency department because of gnawing substernal chest pain that started an hour ago and radiates to his neck and left jaw. A 12-lead ECG is obtained and shows ST-segment elevation with newly developing Q waves. He is admitted for treatment. 4 days after hospitalization he suddenly develops altered mental status, and his blood pressure falls from 115/75 mm Hg to 80/40 mm Hg. Physical examination shows jugular venous distention, pulsus paradoxus, and distant heart sounds. What is the most likely cause of this patient's condition?

A 69-year-old man is scheduled to undergo radical retropubic prostatectomy for prostate cancer in 2 weeks. He had a myocardial infarction at the age of 54 years. He has a history of GERD, unstable angina, hyperlipidemia, and severe osteoarthritis in the left hip. He is unable to climb up stairs or walk fast because of pain in his left hip. He had smoked one pack of cigarettes daily for 30 years but quit 25 years ago. He drinks one glass of wine daily. Current medications include aspirin, metoprolol, lisinopril, rosuvastatin, omeprazole, and ibuprofen as needed. His temperature is 36.4°C (97.5°F), pulse is 90/min, and blood pressure is 136/88 mm Hg. Physical examination shows no abnormalities. A 12-lead ECG shows Q waves and inverted T waves in leads II, III, and aVF. His B-type natriuretic protein is 84 pg/mL (N < 125). Which of the following is the most appropriate next step in management to assess this patient's perioperative cardiac risk?

Q10

A 57-year-old man presents to his primary care provider because of chest pain for the past 3 weeks. The chest pain occurs after climbing more than 2 flight of stairs or walking for more than 10 minutes and resolves with rest. He is obese, has a history of type 2 diabetes mellitus, and has smoked 15-20 cigarettes a day for the past 25 years. His father died from a myocardial infarction at 52 years of age. Vital signs reveal a temperature of 36.7 °C (98.06°F), a blood pressure of 145/93 mm Hg, and a heart rate of 85/min. The physical examination is unremarkable. Which of the following best represents the most likely etiology of the patient’s condition?

Cardiac rehabilitation US Medical PG Practice Questions and MCQs

Question 1: A 45-year-old man presents for his annual checkup. The patient has a past medical history of diabetes mellitus (DM) type 2 that is well-controlled with diet. In addition, he was admitted to this hospital 1-year ago for a myocardial infarction (MI). The patient reports a 40-pack-year smoking history. However, after his MI, his doctors informed him about how detrimental smoking was to his heart condition. Since then, he has made efforts to cut down and now, for the past seven months, has stopped smoking. He says he used to use smoking as a means of dealing with his work and family stresses. He now attends wellness sessions at work and meditates early every morning before the family wakes up. Which of the following stages of the transtheoretical model is this patient most likely in?

A. Preparation
B. Contemplation
C. Action
D. Precontemplation
E. Maintenance (Correct Answer)

Explanation: ***Maintenance*** - The patient has **successfully stopped smoking for seven months**, indicating sustained behavior change. - He has also adopted **new coping mechanisms** like wellness sessions and meditation, which are crucial for preventing relapse and falls under this stage. *Preparation* - This stage involves **intending to take action** in the immediate future (e.g., within the next month) and involves some steps towards change, such as making a plan. - The patient has already acted and sustained the behavior change, moving past mere preparation. *Contemplation* - Individuals in this stage are **aware a problem exists** and are seriously thinking about overcoming it but have not yet committed to taking action. - The patient has clearly moved past just thinking about quitting and has actively stopped smoking. *Action* - This stage involves **modifying behavior, experiences, or environment** in order to overcome problems. - While the patient was in the action stage when he initially quit, he has now maintained this change for an extended period (seven months), progressing beyond the initial action phase. *Precontemplation* - In this stage, individuals are **not intending to take action** in the foreseeable future (e.g., within 6 months) and are often unaware or underaware of their problems. - This patient actively quit smoking and maintained cessation, showing he was not in precontemplation.

Question 2: A 60-year-old male engineer who complains of shortness of breath when walking a few blocks undergoes a cardiac stress test because of concern for coronary artery disease. During the test he asks his cardiologist about what variables are usually used to quantify the functioning of the heart. He learns that one of these variables is stroke volume. Which of the following scenarios would be most likely to lead to a decrease in stroke volume?

A. Anxiety
B. Heart failure (Correct Answer)
C. Exercise
D. Pregnancy
E. Digitalis

Explanation: ***Heart failure*** - In **heart failure**, the heart's pumping ability is impaired, leading to a reduced **ejection fraction** and thus a decreased **stroke volume**. - The weakened myocardium cannot effectively contract to expel the normal volume of blood, resulting in lower blood output per beat. *Anxiety* - **Anxiety** typically causes an increase in **sympathetic nervous system** activity, leading to increased heart rate and myocardial contractility. - This often results in a temporary **increase in stroke volume** due to enhanced cardiac performance, not a decrease. *Exercise* - During **exercise**, there is a significant **increase in venous return** and sympathetic stimulation, leading to increased **end-diastolic volume** and contractility. - This physiological response causes a substantial **increase in stroke volume** to meet the body's higher oxygen demands. *Pregnancy* - **Pregnancy** leads to significant **physiological adaptations** to accommodate the growing fetus, including a substantial increase in **blood volume**. - This increased blood volume and cardiac output result in an **increase in stroke volume** to maintain adequate perfusion for both mother and fetus. *Digitalis* - **Digitalis** is a cardiac glycoside that **increases intracellular calcium** in myocardial cells, enhancing the **force of contraction**. - This positive inotropic effect leads to an **increased stroke volume** by improving the heart's pumping efficiency.

Question 3: A 57-year-old otherwise healthy male presents to his primary care physician for a check-up. He has no complaints. His blood pressure at the previous visit was 160/95. The patient did not wish to be on any medications and at the time attempted to manage his blood pressure with diet and exercise. On repeat measurement of blood pressure today, the reading is 163/92. His physician decides to prescribe a medication which the patient agrees to take. The patient calls his physician 6 days later complaining of a persistent cough, but otherwise states that his BP was measured as 145/85 at a local pharmacy. Which of the following is a contraindication to this medication?

A. Congestive heart failure
B. Black race
C. Bilateral renal artery stenosis (Correct Answer)
D. Chronic obstructive pulmonary disease
E. Gout

Explanation: ***Bilateral renal artery stenosis*** - The patient's developing **cough** after starting a new antihypertensive suggests he was likely prescribed an **ACE inhibitor**. - **Bilateral renal artery stenosis** is a strong contraindication for ACE inhibitors due to the risk of precipitating **acute kidney injury**, as these medications rely on efferent arteriolar vasodilation to maintain renal perfusion when there's reduced afferent flow. *Congestive heart failure* - **ACE inhibitors** are often a **first-line treatment** for heart failure due to their ability to improve cardiac remodeling and reduce mortality. - They are used to prevent ventricular remodeling and reduce afterload, making this an indication, not a contraindication. *Black race* - While ACE inhibitors may be **less effective as monotherapy** in black patients, they are not contraindicated and can be effectively used in combination with other antihypertensives, such as **thiazide diuretics** or **calcium channel blockers**. - **African Americans** often respond better to calcium channel blockers and diuretics for hypertension but ACE inhibitors are not absolutely contraindicated. *Chronic obstructive pulmonary disease* - **ACE inhibitors** are **not contraindicated** in COPD, as they do not affect bronchial smooth muscle tone. - **Beta-blockers**, not ACE inhibitors, are typically avoided or used with caution in patients with reactive airway diseases like asthma or severe COPD. *Gout* - **ACE inhibitors** do not significantly impact **uric acid levels** and are generally safe for use in patients with gout. - In contrast, **thiazide diuretics** can increase uric acid levels and worsen gout, but this is not the medication indicated by the patient's cough.

Question 4: A 56-year-old woman comes to the physician for follow-up after a measurement of elevated blood pressure at her last visit three months ago. She works as a high school teacher at a local school. She says that she mostly eats cafeteria food and take-out. She denies any regular physical activity. She does not smoke or use any recreational drugs. She drinks 2 to 3 glasses of wine per day. She has hypercholesterolemia for which she takes atorvastatin. Her height is 165 cm (5 ft 5 in), weight is 82 kg (181 lb), and BMI is 30.1 kg/m2. Her pulse is 67/min, respirations are 18/min, and blood pressure is 152/87 mm Hg on the right arm and 155/92 mm Hg on the left arm. She would like to try lifestyle modifications to improve her blood pressure before considering pharmacologic therapy. Which of the following lifestyle modifications is most likely to result in the greatest reduction of this patient's systolic blood pressure?

A. Walking for 30 minutes, 5 days per week
B. Reducing sodium intake to less than 2.4 g per day
C. Losing 15 kg (33 lb) of body weight (Correct Answer)
D. Adopting a DASH diet
E. Decreasing alcohol consumption to maximum of one drink per day

Explanation: ***Losing 15 kg (33 lb) of body weight*** - **Weight reduction** is the most effective lifestyle modification for lowering blood pressure, correlating directly with the amount of weight lost. - A loss of 15 kg (33 lb) in this patient, who is **obese (BMI 30.1)**, could significantly reduce her systolic blood pressure, potentially by 5-20 mmHg per 10 kg weight loss. *Walking for 30 minutes, 5 days per week* - Regular **aerobic physical activity** is beneficial for blood pressure reduction, typically resulting in a 4-9 mmHg decrease in systolic pressure. - While helpful, the magnitude of reduction from exercise alone is generally less than that achieved with significant weight loss in an obese individual. *Reducing sodium intake to less than 2.4 g per day* - **Sodium restriction** is an effective strategy, often leading to a 2-8 mmHg reduction in systolic blood pressure. - Given the patient's diet of cafeteria and take-out food, high sodium intake is likely, making this a relevant intervention, but typically less impactful than substantial weight loss. *Adopting a DASH diet* - The **Dietary Approaches to Stop Hypertension (DASH) diet** emphasizes fruits, vegetables, and low-fat dairy, and can significantly lower blood pressure, by 8-14 mmHg. - This diet is highly effective, but for an obese individual, the blood pressure reduction from achieving a healthy weight is often greater. *Decreasing alcohol consumption to maximum of one drink per day* - Reducing **excessive alcohol intake** can decrease systolic blood pressure by 2-4 mmHg, as the patient reports 2-3 glasses of wine daily. - While beneficial, this reduction is likely to be less substantial compared to major weight loss or other dietary changes.

Question 5: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

A. "Does the diarrhea typically precede the constipation, or vice-versa?"
B. "Is the diarrhea foul-smelling?"
C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
D. "Are the symptoms worse in the morning or at night?"
E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)

Explanation: ***Can you tell me more about the symptoms you have been experiencing?*** - This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis. - In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions. *Does the diarrhea typically precede the constipation, or vice-versa?* - While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience. - It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture. *Is the diarrhea foul-smelling?* - Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions. - However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed. *Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life* - Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time. - However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially. *Are the symptoms worse in the morning or at night?* - Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related. - This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.

Question 6: A 62-year-old man with a past medical history of previous myocardial infarction, angina, hypertension, hyperlipidemia, diabetes mellitus, peripheral vascular disease, and below knee amputation has developed new chest pain. His medication includes insulin, hydrochlorothiazide, lisinopril, metoprolol, daily aspirin, atorvastatin, and nitroglycerin as needed. His vitals include: blood pressure 135/87 mm Hg, pulse 52/min, and respirations 17/min. Coronary arteriography shows a reduced ejection fraction, a 65% stenosis of the left anterior descending artery, and a 75% stenosis of the left circumflex artery. Which of the following is the recommended treatment for the patient?

A. Increased beta blocker dosage
B. Coronary artery bypass grafting (CABG) (Correct Answer)
C. Angioplasty with stent placement
D. Extended release nitrate therapy
E. Heparin

Explanation: ***Coronary artery bypass grafting (CABG)*** - This patient has complex **multivessel coronary artery disease** (LAD and circumflex stenosis) with a **reduced ejection fraction** and a history of multiple comorbidities, making CABG the preferred revascularization strategy for improved outcomes. - CABG offers a more complete revascularization in patients with significant disease burden and reduced left ventricular function, leading to better long-term survival and symptom relief compared to PCI in this population. *Increased beta blocker dosage* - The patient's current heart rate is 52/min, which is already at the lower end of the target range for beta-blocker therapy in cardiac patients, and further increasing the dose could lead to **bradycardia** and worsening symptoms. - While beta-blockers are crucial for managing angina and improving outcomes post-MI, increasing the dose wouldn't address the underlying anatomical severe multi-vessel coronary artery disease. *Angioplasty with stent placement* - Although PCI (angioplasty with stent placement) can be used for coronary stenosis, in patients with **multivessel disease**, **reduced ejection fraction**, and **diabetes mellitus**, CABG generally offers superior long-term results and survival benefits. - The complexity of the lesions (65% LAD, 75% circumflex) in a patient with significant comorbidities and extensive atherosclerotic disease makes PCI a less optimal choice here. *Extended release nitrate therapy* - Nitrates primarily provide **symptomatic relief** by causing vasodilation, but they do not address the severe underlying coronary stenoses or improve long-term outcomes in patients with complex, multivessel disease. - The patient is already on PRN nitroglycerin, and while extended-release nitrates could help with angina, they are not a definitive treatment for significant arterial blockages requiring revascularization. *Heparin* - Heparin is an **anticoagulant** that may be used as part of initial management of acute coronary syndromes, but it provides only temporary stabilization and does not address the **definitive need for revascularization**. - While anticoagulation plays a role in acute management, this patient requires **definitive anatomical correction** of his multivessel disease with significant stenoses, which only surgical or percutaneous revascularization can provide, with CABG being superior given his clinical profile.

Question 7: An 18-year-old boy is brought to the emergency department by his parents because he suddenly collapsed while playing football. His parents mention that he had complained of dizziness while playing before, but never fainted in the middle of a game. On physical examination, the blood pressure is 130/90 mm Hg, the respirations are 15/min, and the pulse is 110/min. The chest is clear, but a systolic ejection murmur is present. The remainder of the examination revealed no significant findings. An electrocardiogram is ordered, along with an echocardiogram. He is diagnosed with hypertrophic cardiomyopathy and the physician lists all the precautions he must follow. Which of the following drugs will be on the list of contraindicated substances?

A. Βeta-blockers
B. Dobutamine
C. Nitrates (Correct Answer)
D. Calcium channel blockers
E. Potassium channel blockers

Explanation: ***Nitrates*** - **Nitrates** cause **vasodilation**, which decreases **preload** and worsens **left ventricular outflow tract obstruction (LVOTO)** in **hypertrophic cardiomyopathy (HCM)**, potentially leading to syncope or sudden death. - Reduced preload exacerbates the dynamic obstruction, causing a critical drop in cardiac output. - **Commonly encountered substances** patients must avoid include nitroglycerin, isosorbide, and **phosphodiesterase-5 inhibitors** (sildenafil, tadalafil) which potentiate nitrate effects. - This is a critical counseling point for HCM patients in everyday life. *Beta-blockers* - **Beta-blockers** are **first-line treatment** for **hypertrophic cardiomyopathy (HCM)** as they reduce heart rate, improve diastolic filling, and decrease contractility, thereby reducing **LVOTO**. - They alleviate symptoms and reduce the risk of sudden cardiac death in HCM. *Dobutamine* - **Dobutamine** is a **beta-1 adrenergic agonist** that increases contractility and heart rate, which would worsen **LVOTO** in HCM. - While also contraindicated in HCM, dobutamine is only used in **controlled hospital settings** for stress testing or hemodynamic support, not a substance patients encounter in daily life. - The question focuses on outpatient counseling about substances to avoid in everyday situations. *Calcium channel blockers* - **Non-dihydropyridine calcium channel blockers** (verapamil, diltiazem) are used in **HCM management**, particularly in patients who cannot tolerate beta-blockers. - They improve **diastolic function** and reduce **LVOTO** by decreasing contractility and heart rate. - **Caution:** Dihydropyridines (nifedipine, amlodipine) can worsen obstruction and should be avoided. *Potassium channel blockers* - **Antiarrhythmics** like **amiodarone** (potassium channel blocker) are used in **HCM** patients for atrial or ventricular arrhythmias. - Not contraindicated; therapeutically indicated for rhythm management.

Question 8: An 80-year-old man presents to the emergency department because of gnawing substernal chest pain that started an hour ago and radiates to his neck and left jaw. A 12-lead ECG is obtained and shows ST-segment elevation with newly developing Q waves. He is admitted for treatment. 4 days after hospitalization he suddenly develops altered mental status, and his blood pressure falls from 115/75 mm Hg to 80/40 mm Hg. Physical examination shows jugular venous distention, pulsus paradoxus, and distant heart sounds. What is the most likely cause of this patient's condition?

A. Pericardial inflammation
B. Compression of heart chambers by blood in the pericardial space (Correct Answer)
C. Arrhythmia caused by ventricular fibrillation
D. Rupture of papillary muscle
E. Acute pulmonary edema from left heart failure

Explanation: ***Compression of heart chambers by blood in the pericardial space*** - The patient's initial presentation with ST-elevation myocardial infarction (STEMI) and subsequent development of **hypotension**, **jugular venous distention**, **pulsus paradoxus**, and **distant heart sounds** (Beck's triad) is highly indicative of **cardiac tamponade.** - In the context of a recent MI, this constellation of symptoms strongly suggests a **cardiac free wall rupture**, leading to blood accumulation in the pericardial sac and compression of the heart. - Free wall rupture typically occurs **3-7 days post-MI** and is a life-threatening mechanical complication. *Pericardial inflammation* - While pericardial inflammation (pericarditis) can occur post-MI, it typically manifests with **pleuritic chest pain** that is relieved by leaning forward and is often associated with a **pericardial friction rub.** - It does not typically lead to acute, severe hypotension, pulsus paradoxus, or sudden circulatory collapse in this manner without significant effusion and tamponade physiology. *Arrhythmia caused by ventricular fibrillation* - **Ventricular fibrillation** would cause immediate cardiac arrest and loss of consciousness, not a gradual development of hypotension, JVD, and pulsus paradoxus. - While arrhythmias are common post-MI, the specific physical findings point away from isolated VFib as the primary cause of hemodynamic collapse. *Acute pulmonary edema from left heart failure* - **Acute pulmonary edema** is a manifestation of **left heart failure**, characterized by severe dyspnea, orthopnea, and crackles on lung auscultation. - While left heart failure can cause hypotension in cardiogenic shock, it would not typically present with the classic signs of cardiac tamponade such as pulsus paradoxus, distant heart sounds, and prominent JVD without pulmonary congestion findings. *Rupture of papillary muscle* - **Papillary muscle rupture** leads to severe **acute mitral regurgitation**, causing acute pulmonary edema, a new holosystolic murmur, and often cardiogenic shock. - While it can lead to hypotension, it doesn't typically present with the classic signs of cardiac tamponade such as pulsus paradoxus and distant heart sounds; instead, a loud murmur would be prominent.

Question 9: A 69-year-old man is scheduled to undergo radical retropubic prostatectomy for prostate cancer in 2 weeks. He had a myocardial infarction at the age of 54 years. He has a history of GERD, unstable angina, hyperlipidemia, and severe osteoarthritis in the left hip. He is unable to climb up stairs or walk fast because of pain in his left hip. He had smoked one pack of cigarettes daily for 30 years but quit 25 years ago. He drinks one glass of wine daily. Current medications include aspirin, metoprolol, lisinopril, rosuvastatin, omeprazole, and ibuprofen as needed. His temperature is 36.4°C (97.5°F), pulse is 90/min, and blood pressure is 136/88 mm Hg. Physical examination shows no abnormalities. A 12-lead ECG shows Q waves and inverted T waves in leads II, III, and aVF. His B-type natriuretic protein is 84 pg/mL (N < 125). Which of the following is the most appropriate next step in management to assess this patient's perioperative cardiac risk?

A. No further testing
B. 24-hour ambulatory ECG monitoring
C. Radionuclide myocardial perfusion imaging (Correct Answer)
D. Treadmill stress test
E. Resting echocardiography

Explanation: ***Radionuclide myocardial perfusion imaging*** - This patient requires **perioperative cardiac risk assessment** before intermediate-risk surgery (radical prostatectomy). - Key factors include: history of **myocardial infarction**, current cardiac risk factors, and **inability to exercise** due to severe osteoarthritis. - Since he cannot perform exercise stress testing, **pharmacologic stress testing** with radionuclide myocardial perfusion imaging (using agents like adenosine, dipyridamole, or regadenoson) is the most appropriate test to assess for **inducible myocardial ischemia**. - This provides functional assessment of coronary perfusion under pharmacologic stress, helping guide perioperative risk stratification and management. - *Note: The presence of unstable angina would typically require cardiac stabilization first; this question focuses on selecting the appropriate stress test modality for a patient unable to exercise.* *No further testing* - This patient has significant cardiac risk factors including **prior MI**, ongoing cardiac medications, and ECG changes suggesting old infarction. - Proceeding directly to surgery without functional cardiac assessment would be **inappropriate** given his risk profile and the intermediate-risk nature of the planned surgery. *24-hour ambulatory ECG monitoring* - Holter monitoring detects arrhythmias and silent ischemic episodes but does not provide **functional capacity assessment** or evaluation of inducible ischemia under stress conditions. - It is not the primary tool for **perioperative cardiac risk stratification** before major surgery. *Treadmill stress test* - The patient's **severe osteoarthritis** prevents him from climbing stairs or walking fast, making him unable to achieve adequate exercise workload for a treadmill stress test. - This functional limitation makes **exercise stress testing contraindicated**; pharmacologic stress testing is required instead. *Resting echocardiography* - Resting echocardiography assesses **baseline left ventricular function**, wall motion abnormalities from prior infarction, and valvular disease. - While useful for structural assessment, it does **not evaluate for exercise-induced or stress-induced ischemia**, which is critical for perioperative risk assessment in patients with coronary artery disease. - His normal BNP (84 pg/mL) suggests adequate baseline ventricular function, making functional ischemia assessment more relevant than structural evaluation alone.

Question 10: A 57-year-old man presents to his primary care provider because of chest pain for the past 3 weeks. The chest pain occurs after climbing more than 2 flight of stairs or walking for more than 10 minutes and resolves with rest. He is obese, has a history of type 2 diabetes mellitus, and has smoked 15-20 cigarettes a day for the past 25 years. His father died from a myocardial infarction at 52 years of age. Vital signs reveal a temperature of 36.7 °C (98.06°F), a blood pressure of 145/93 mm Hg, and a heart rate of 85/min. The physical examination is unremarkable. Which of the following best represents the most likely etiology of the patient’s condition?

A. Hypertrophy of the interventricular septum
B. Multivessel atherosclerotic disease with or without a nonocclusive thrombus
C. Intermittent coronary vasospasm with or without coronary atherosclerosis
D. Fixed, atherosclerotic coronary stenosis (> 70%) (Correct Answer)
E. Sudden disruption of an atheromatous plaque, with a resulting occlusive thrombus

Explanation: ***Fixed, atherosclerotic coronary stenosis (> 70%)*** - The patient's presentation with **exertional chest pain** that resolves with rest (stable angina), along with multiple **cardiovascular risk factors** (obesity, type 2 diabetes mellitus, smoking, family history of early MI, hypertension), strongly points towards **stable ischemic heart disease**. - This clinical picture is typically caused by a **fixed, hemodynamically significant stenosis** in one or more coronary arteries, usually greater than 70%, that limits blood flow during increased demand. *Multivessel atherosclerotic disease with or without a nonocclusive thrombus* - While the patient likely has **multivessel atherosclerosis**, the phrase "with or without a nonocclusive thrombus" leans towards **unstable angina** or NSTEMI, which typically involves a sudden change in symptoms or rest angina. - The patient's symptoms are **stable and reproducible** with exertion, resolving with rest, which is characteristic of stable angina rather than a thrombotic event. *Sudden disruption of an atheromatous plaque, with a resulting occlusive thrombus* - This mechanism describes an **acute coronary syndrome (ACS)**, such as an **ST-elevation myocardial infarction (STEMI)** or **non-ST-elevation myocardial infarction (NSTEMI)**. - ACS typically presents with new-onset, worsening, or rest angina, which is different from the stable, exertional pattern described in the patient. *Intermittent coronary vasospasm with or without coronary atherosclerosis* - **Coronary vasospasm** (e.g., Prinzmetal angina) typically causes chest pain that occurs **at rest**, often at night or in the early morning, and is not necessarily related to exertion. - While the patient could have underlying atherosclerosis, the **predictable exertional nature** of his symptoms makes vasospasm less likely as the primary etiology. *Hypertrophy of the interventricular septum* - **Interventricular septal hypertrophy** is characteristic of **hypertrophic cardiomyopathy (HCM)**, which can cause exertional chest pain due to outflow tract obstruction or myocardial ischemia. - However, HCM is less likely to be the primary etiology in a 57-year-old with multiple classic **atherosclerotic risk factors** and no mention of a heart murmur or family history of HCM.

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