Cardiology

In patients with any cardiovascular disease who had an implantable cardioverter–defibrillator (ICD) and were at high risk for ventricular arrhythmias, a treatment-induced increase in plasma potassium levels to a high-normal level (4.5 to 5.0 mmol per liter) led to a significantly lower risk of  documented sustained ventricular tachycardia or appropriate ICD therapy, unplanned hospitalization for arrhythmia or heart failure, or death from any cause.

• True
• False

Which one of the following statements regarding diuretics in heart failure is false?

• Thiazides are ineffective as the sole diuretic agent in more advanced states of heart failure.
• Loop diuretics have a potent natriuretic effect.
• Loop diuretics have reduced efficacy in hypoalbuminemia and moderate to severe chronic kidney disease.
• Furosemide has better oral bioavailability than bumetanide.

Among previously coffee-drinking patients with AF referred for cardioversion, typical consumption of caffeinated coffee averaging 1 cup a day is associated with less recurrence of AF and atrial flutter compared with abstinence from coffee and caffeinated products.

• True
• False

Which one of the following statements about a fixed-dose combination of sacubitril/valsartan in the treatment of heart failure with reduced ejection fraction is false?

• It is preferred over an ACE inhibitor or an ARB.
• It should be started at least 36 hours after stopping ACE inhibitor treatment.
• It causes less hypotension than ARBs.
• It causes hyperkalemia more often than ARBs.

Among patients discharged after invasive care for a myocardial infarction with a left ventricular ejection fraction above 40%, beta-blocker therapy improves a composite outcome of the incidence of death from any cause, reinfarction or hospitalization for heart failure.

• True
• False

For patients with symptomatic peripheral artery disease, low-dose rivaroxaban combined with low-dose aspirin is recommended to reduce risk of major adverse cardiovascular events.

• True
• False

More intensive blood pressure treatment modestly reduces the occurrence of orthostatic hypertension.

• True
• False

In patients with Acute Coronary Syndrome undergoing drug-eluting stent implantation, de-escalating Dual Antiplatelet Therapy (DAPT) to ticagrelor monotherapy is associated with a lower risk for major bleeding without increasing the risk for ischemic events compared with standard DAPT.

• True
• False

Automated blood pressure readings in a noisy public space yield similar results to those obtained in a quiet office setting.

• True
• False

Which one of the following statements regarding atrial fibrillation and older adults is false?

• High intensity exercise is associated with decreased incidence of atrial fibrillation.
• Catheter ablation may improve cognition in older adults with atrial fibrillation.
• Weight loss may reverse atrial fibrillation from persistent to paroxysmal.
• DOACs are favored over warfarin for most patients.

Which one of the following statements about chronic venous insufficiency is false?

• Venous insufficiency increases the risk of venous thrombotic events.
• Swelling of the dorsum of the foot indicates lymphatic dysfunction.
• Duplex ultrasound evaluation can discern venous hypertension.
• When necessary, thiazides and mineralocorticoid antagonist diuretics are preferred over loop diuretics.

Which one of the following statements about calcific aortic stenosis is false?

• Auscultation of a cardiac murmur has a sensitivity less than 50 %.
• Hypertension is associated with a 2-fold higher rate of valve calcification.
• Direct oral anticoagulant medications are contraindicated in patients with mechanical heart valves.
• Antibiotic prophylaxis is not recommended for routine dental cleanings in patients with a prosthetic valve.

Which one of the following statements about the management of atrial fibrillation (AF) is false?

• Rate rather than rhythm control is recommended for patients with AF within 1 year of diagnosis and high-risk features.
• Rivaroxiban alone is adequate for stroke prevention in most patients with AF and coronary artery disease.
• In younger individuals with symptomatic paroxysmal AF, ablation is recommended as first-line treatment.
• Up to 50% of patients require repeated ablation for durable rhythm control.

Wearable heart monitors (i.e. smartwatches) are accurate in detecting atrial fibrillation.

• True
• False

Which one of the following statements regarding pericarditis is false?

• Most patients have a benign course with appropriate treatment.  
• Gastroprotection with a proton pump inhibitor is recommended for patients taking high dose NSAIDs.
• A 3-month course of colchicine is recommended for acute idiopathic pericarditis to prevent recurrence.
• High dose corticosteroids reduce recurrence.

Which one of the following statements regarding cardiac injury after non-cardiac surgery is false?

• The estimated incidence is about 20%.
• Most present with symptoms related to ischemia.
• It is higher after nonelective procedures.
• It is associated with increased 30-day mortality.

In patients with atrial fibrillation and stable coronary artery disease, edoxaban monotherapy leads to a lower risk of a composite of death from any cause, myocardial infarction, stroke, systemic embolism, unplanned urgent revascularization, or major bleeding or clinically relevant nonmajor bleeding at 12 months than dual antithrombotic therapy (edoxaban plus a single antiplatelet agent).

• True
• False

In patients with coronary artery disease, rosuvastatin is more effective than atorvastatin in reducing the composite risk of myocardial infarction, stroke, coronary revascularization, and all-cause mortality.

• True
• False

Which one of the following statements about heart failure with preserved ejection fraction (HFpEF) is false?

• Approximately 20% of patients with HFpEF have normal natriuretic peptide levels.
• It is associated with low socioeconomic status.
• HFpEF comprises a larger percentage of heart failure in men than in women.
• SGLT2 inhibitors are an effective treatment.

Catheter ablation for atrial fibrillation is associated with reduced risk of heart failure events in patients with heart failure with reduced ejection fraction.

• True
• False

Among patients at increased risk for heart failure after acute myocardial infarction, treatment with empagliflozin has been shown to significantly lower the risk of a first hospitalization for heart failure or death from any cause. 

• True
• False

In patients with an acute coronary syndrome who had percutaneous coronary intervention with drug-eluting stents and remained event-free for 1 month on dual antiplatelet therapy, treatment with ticagrelor alone between month 1 and month 12 after the intervention results in a lower rate of clinically relevant bleeding with similar cardiovascular and cerebrovascular  outcomes compared with ticagrelor and aspirin.  

• True
• False

For patients with severe aortic stenosis who are not suitable candidates for valve replacement, non-invasive ultrasound therapy improves valve function at 6 months. 

• True
• False

Which one of the following regarding lipid management in the prevention of cardiovascular disease is true?   

• Apolipoprotein B should be used when assessing cardiovascular risk.   
• Prevention should target specific lipid levels.   
• Coronary artery calcium levels should be used in assessing cardiovascular risk.   
• Nonfasting lipid levels can be used to calculate global cardiovascular disease risk. 

In patients with subclinical atrial fibrillation and risk factors for stroke, apixaban resulted in a lower risk of stroke or systemic embolism than aspirin.

• True
• False

Radiofrequency catheter ablation is now considered first-line treatment for rhythm control in patients with atrial fibrillation.

• True
• False

Among patients with stage 4 Chronic Kidney Disease and poorly controlled hypertension, treatment with chlorthalidone reduces albuminuria.

• True
• False

In in-hospital cardiac arrest due to a shockable rhythm, treatment with epinephrine before defibrillation is associated with worse survival.

• True
• False

Which one of the following statements about palpitations is false? 

• A high burden of premature ventricular complexes (PVC) is associated with an increased risk of PVC-induced cardiomyopathy.   
• A regular, rapid pounding sensation in the neck is usually associated with an increased probability of atrioventricular nodal re-entrant tachycardia.   
• Palpitations that occur at work increase the likelihood of a cardiac cause.   
• Palpitations associated with sudden change in position such as bending forward are more likely due to high burden of PVC. 

Which one of the following statements about atrial fibrillation is false? 

• It is associated with an increased risk of dementia.   
• 5-10% of patients with paroxysmal atrial fibrillation will have progression to persistent atrial fibrillation per year.   
• The risk of stroke or embolic events is about the same in patients taking warfarin as in those taking direct-acting oral anticoagulants.   
• In observational studies, apixaban has been associated with less bleeding risk than rivaroxaban. 

In typical patients who present with supraventricular tachycardia there is good evidence to support troponin testing. 

• True
• False

Which one for the following statements about the use of lung point of care ultrasonography in the management of fluid balance in congestive heart failure is false? 

• It is associated with a reduced cumulative fluid balance.    
• There is a consistent decrease in hospitalizations and mortality.   
• It is not associated with any adverse effects related to hypoperfusion.    
• It has been shown to out-perform traditional pulmonary edema evaluation methods regarding accuracy.  

Which one of the following statements about POTS (postural orthostatic tachycardia syndrome) is false?

• Orthostatic hypotension precludes the diagnosis of POTS.
• Most patients with POTS have low cardiac stroke volume.
• Numerous cases of POTS after SARS-CoV-2 infection have been reported.
• A tilt table test is required for diagnosis.

In patients with peripheral arterial disease (PAD), low intensity walking (walking that does not provoke ischemic symptoms) is as effective as high intensity walking (walking at a pace that provokes symptoms) in improving walking distance. 

• True
• False

Which one of the following statements about the use of catheter ablation as a first-line strategy in patients with paroxysmal atrial fibrillation compared with use of antiarrhythmic drugs is false?  

• It is associated with reductions in recurrent atrial arrhythmia.   
• It is associated with reduced symptomatic atrial arrhythmia.   
• It results in reduced hospitalization.   
• It results in fewer serious adverse events. 

Vitamin D supplementation reduces the incidence of atrial fibrillation among adults aged 50 or older.  

• True
• False

Which one of the following statements about peripartum cardiomyopathy is false?  

• Diagnosis may be delayed due to resemblance to normal symptoms of pregnancy.   
• Brain natriuretic peptide is usually normal.   
• If left ventricular ejection fraction is < 50%, then future pregnancy is associated with risk of durable deterioration of cardiac function.    
• Estrogen-containing contraceptives should be avoided in the early post-partum setting if severe left ventricular dysfunction is present.  

Early rhythm-control therapy is associated with a lower risk of adverse cardiovascular outcomes than usual care among patients with early atrial fibrillation and cardiovascular conditions. 

• True
• False

Which one of the following statements about management of patients with a patent foramen ovale (PFO) with a history of stroke is false? 

• The prevalence of PFO in the general population is approximately 25%.   
• Evaluation for atrial fibrillation should be done prior to considering PFO closure.   
• Stroke incidence is reduced with PFO closure compared to antiplatelet therapy.   
• PFO closure is not recommended before age 60. 

Among patients who have been successfully resuscitated after out-of-hospital cardiac arrest and have no signs of ST Elevation Myocardial Infarction (STEMI) on ECG, a strategy of immediate angiography is better than a strategy of delayed angiography with respect to overall survival at 30 days.

• True
• False

Which one of the following cardiovascular effects is not associated with cannabis use in young adults?

• Decreased heart rate
• Increased myocardial oxygen demand
• Platelet activation
• Decreased ventricular contractility

For individuals who have a history of stroke or who are 60 years of age or older and have high blood pressure, sparing use of a salt substitute (75% sodium chloride and 25% potassium chloride by mass) rather than regular salt use lowers the rate of stroke.

• True
• False

Which one of the following statements about blood pressure monitoring is false?

• Bladder cuff width should be 37% to 50% of the arm circumference.
• Patients should avoid caffeine for 30 minutes prior to a measurement.
• Wrist cuffs are not recommended.
• Blood pressure kiosks located in pharmacies are a substitute for home blood pressure monitoring.

Which one of the following statements about home blood pressure monitoring is false?

• It is less sensitive for the diagnosis of hypertension than in-office blood pressure measurements.
• The first day of readings tend to be more elevated than other readings.
• It can identify masked hypertension.
• No further medication adjustment is recommended if blood pressure is at goal on home blood pressure monitoring, even if measurements are elevated in the office.

The association between recent cannabis use and myocardial infarction in young adults has been found to be similar in magnitude to that observed for current tobacco smoking.

• True
• False

Which one of the following statements about pulmonary arterial hypertension is false?

• Diagnosis is delayed in many cases as symptoms are nonspecific.  
• Murmur of tricuspid regurgitation is suggestive.
• Right heart catheterization is not required for diagnosis.
• Atrial septostomy is a treatment option in some cases.

In the treatment of atrial fibrillation in patients age 65 or older, rivaroxaban compared with apixaban is associated with a significantly increased risk of major ischemic events.

• True
• False

Which one of the following statements about the use of empagliflozin in patients with heart failure and preserved ejection fraction is false?

• It reduces the combined risk of cardiovascular death or hospitalization in patients with diabetes.
• It does not reduce the combined risk of cardiovascular death or hospitalization in patients without diabetes.
• It increases the risk of uncomplicated urinary tract infections.
• It increases the risk of hypotension.

 Dapagliflozin reduced the combined risk of worsening heart failure or cardiovascular death among patients with heart failure and a mildly reduced or preserved ejection fraction. 

• True
• False

Which one of the following statements about the use of biomarkers in risk stratification of cardiovascular disease is false?

• There is a linear relationship between future cardiovascular risk and lipoprotein (a) levels.
• Addition of apolipoprotein B to models that already include total cholesterol and HDL-C has led to improvement in risk stratification.
• Coronary Artery Calcium (CAC) score of 0 gives a low risk of 10 year ASCVD.
• The addition of Lipoprotein(a) to models that already include total cholesterol and HDL-C has NOT led to improvement in risk stratification.

In patients with heart failure with preserved ejection fraction, empagliflozin reduces the risk of hospitalization for heart failure.

• True
• False

Which one of the following statements about myocardial infarction is false?

• Type 2 myocardial infarction is seen in patients with hypoxemia.
• Coronary artery dissection is an etiology of type 1 myocardial infarction.
• Half of all troponin elevations are attributable to type 2 myocardial infarction or injury.
• Coronary artery disease is identified in two-thirds of patients with type 2 myocardial infarction after systematic imaging.

In patients with acute coronary syndromes, prasugrel and ticagrelor in addition to Acetylsalicylic acid (ASA) are associated with a further 15% to 20% relative risk reduction of ischemic events compared with clopidogrel.

• True
• False

Combination eicosapentaenoic acid and docosahexaenoic acid preparations have not shown benefit in secondary cardiovascular disease prevention in patients who are appropriately prescribed statins. 

• True
• False

In patients with severe ischemic left ventricular systolic dysfunction receiving optimal medical therapy, revascularization by percutaneous coronary intervention results in a lower incidence of death from any cause or hospitalization for heart failure.

• True
• False

A 50-year-old man comes to the ER complaining of recent onset chest heaviness, leg swelling and trouble breathing at night. He is referred urgently to the cardiology service where he undergoes angiography. This reveals “normal coronary anatomy and no evidence of valvular disease, but there appears to be an element of left ventricular dilatation, in keeping with dilated cardiomyopathy”. The cardiologist recommends that the patient be investigated for his dilated cardiomyopathy.