a = new Array(230);
var f = "<FONT FACE=ARIAL SIZE=2>"
a[0] = ""
a[1] = f + "(A) Incorrect. This is a very rare malignancy that typically appears in soft tissues."
a[2] = f + "(B) Incorrect. There is a very rare neoplasm called a polycystic tumor of the AV node that has mesothelial differentiation. Though small, it can lead to arrhythmias."
a[3] = f + "(C) Incorrect. This neoplasm is usually found in one of the atria. It can produce obstruction of the AV valve (a 'ball-valve' effect)."
a[4] = f + "(D) CORRECT. This is a rare neoplasm (all cardiac neoplasms are rare) but the size alone suggests a malignancy."
a[5] = f + "(E) Incorrect. This is a small excresence on a valve leaflet. It is uncommon."
a[5.1] = f + "(F) Incorrect. Kaposi sarcoma is seen in visceral locations in its epidemic form, now commonly associated with AIDS. The lesions are typically multiple and small. Involvement of the heart is rare."
a[5.2] = f + "(G) Incorrect. Rhabdomyomas are uncommon. Some are seen in assocciation with tuberous sclerosis. They are typically not hemorrhagic or necrotic."
a[6] = f + "(A) Incorrect. Collagenization becomes more prominent following the first week after a myocardial infarction as healing continues. After a couple of weeks, the infarct consists mainly of collagen."
a[7] = f + "(B) Incorrect. Granulation tissue is most prominent after about a week after infarction and then collagenization becomes more prominent."
a[8] = f + "(C) CORRECT. After about 4 days following infarction, the muscle will still be necrotic and many neutrophils will persist, while macrophage infiltration will be beginning."
a[9] = f + "(D) Incorrect. Granulomatous inflammation is not typical for infarction."
a[10] = f + "(E) Incorrect. Chronic inflammation is more typical for viral myocarditis, not infarction."
a[11] = f + "(A) Incorrect. This is probably the most common cause for left ventricular hypertrophy. The left atrium is not typically enlarged."
a[12] = f + "(B) Incorrect. Cardiomyopathies generally involve all heart chambers, including left ventricular hypertrophy with dilation, as well as right ventricular hypertrophy and dilation."
a[13] = f + "(C) CORRECT. Mitral valve stenosis leads to left atrial enlargement, but the left ventricle is usually small. THere is typically a 'fishmouth' shaped mitral valve that has stenosis as well as insufficiency, since it does not close completely. Most mitral valvular disease in adults results from rheumatic valvulitis. The episode(s) of rheumatic fever occurred years before."
a[14] = f + "(D) Incorrect. The increased pressure load from the coarctation would lead to left ventricular hypertrophy."
a[15] = f + "(E) Incorrect. This would lead to hypertension and left ventricular hypertrophy."
a[16] = f + "(A) Incorrect. A contusion would not be a major consequence of injury from a sharp object."
a[17] = f + "(B) Incorrect. Aortic laceration is possible, but the heart (in a more anterior location and of a larger size) is the more likely target."
a[18] = f + "(C) CORRECT. A stab wound into heart can lead to hemopericardium with tamponade."
a[19] = f + "(D) Incorrect. It is possible that the stab wound could introduce infectious agents into heart, but this is not the major acute problem."
a[20] = f + "(E) Incorrect. Infarctions are a function of coronary artery disease. It is unlikely that a major coronary artery would be directly injured."
a[21] = f + "(A) Incorrect. Abnormalities of the beta-myosin gene may be associated with some forms of dilated cardiomyopathy."
a[22] = f + "(B) Incorrect. The CFTR gene is associated with cystic fibrosis. The obstructive lung disease from widespread bronchiectasis that results from cystic fibrosis involving the lung can lead to pulmonary hypertension with cor pulmonale."
a[23] = f + "(C) Incorrect. The fibroblast growth factor receptor gene mutations can be associated with skeletal dysplasias."
a[24] = f + "(D) CORRECT. Marfan syndrome is a connective tissue disorder that is associated with floppy mitral valve and also with cystic medial necrosis that predisposes to aortic dissection."
a[25] = f + "(E) Incorrect. The spectrin gene mutation can be associated with red cell membrane abnormalities associated with hereditary spherocytosis. Anemias in adults with this condition are not typically severe, though anemias in general can increase cardiac stress."
a[25.1] = f + "(F) Incorrect. The dystrophin gene is mutated with Duchenne muscular dystrophy, affecting striated muscle, which can lead to cardiac failure as the disease progresses."
a[26] = f + "(A) Incorrect. This is most common in children who have not been adequately treated for a strep throat, a pharyngitis with group A beta hemolytic streptococcus. There may be a myocarditis with rheumatic fever as well."
a[27] = f + "(B) Incorrect. Mitral valve disease tends to be symptomatic early and then become slowly progressive over years."
a[28] = f + "(C) Incorrect. An atherosclerotic aneurysm of the aorta is typically located below the renal arteries and can cause abdominal pain when it enlarges."
a[29] = f + "(D) CORRECT. Senile calcific aortic stenosis is a condition in which there is gradual calcification of a an aortic valve with three cusps. The condition is seen in the elderly and is idiopathic. Aortic valvular stenosis may not manifest itself clinically until there is narrowing of the outflow orifice to less than 1 square centimeter. Aortic valve disease can remain silent and then suddenly result in symptoms."
a[30] = f + "(E) Incorrect. This is associated with signs of infection, such as fever, murmur, and splenomegaly. Sometimes splinter hemorrhages in nail beds can be seen."
a[31] = f + "(A) Incorrect. These findings are found with chronic rheumatic valvulitis that is typically seen in adults years after episode(s) of rheumatic fever."
a[32] = f + "(B) CORRECT. She has coarctation of the aorta, and the constriction is postductal, allowing prolonged survival. Her physical characteristics also suggest Turner syndrome (monosomy X)."
a[33] = f + "(C) Incorrect. Some forms of aortic stenosis can have supravalvular narrowing."
a[34] = f + "(D) Incorrect. When the spiral septum does not develop properly, a truncus arteriosus can result, with mixing of right and left heart blood, leading to cyanosis."
a[35] = f + "(E) Incorrect. A single AV valve would not lead to selective hypertension in upper extremities. Endocardial cushion defects can be seen with trisomy 21."
a[36] = f + "(A) Incorrect. Abdominal pain could be caused from mesenteric artery thrombosis from bowel infarction, but there should be no pulsatile mass."
a[37] = f + "(B) CORRECT. The aorta involved with an atherosclerotic aneurysm is markedly enlarged and filled with thrombus. Risk factors for atherosclerosis include both diabetes mellitus and hypertension. Atherosclerotic aortic aneurysms are typically located in the abdominal portion below the renal arteries."
a[38] = f + "(C) Incorrect. Arteritides do not cause significant arterial enlargement, and polyarteritis does not affect the aorta."
a[39] = f + "(D) Incorrect. Septic embolization could produce a mycotic aneurysm, but this would be rare in the abdominal aorta."
a[40] = f + "(E) Incorrect. Medial calcific sclerosis involves small muscular arteries and is an incidental finding."
a[41] = f + "(A) Incorrect. SLE can produce a serous pericarditis with an effusion. In a few cases SLE can produce a Libman-Sacks endocarditis, but valvular scarring does not regularly occur."
a[42] = f + "(B) Incorrect. There may be some degree of cardiac enlargement, including the left atrium, with the heart failure produced by ischemic heart disease, including myocardial infarction, but it is not marked, and valves are not scarred or stenotic as a consequence."
a[43] = f + "(C) Incorrect. Small valvular vegetations of non-bacterial thrombotic endocarditis are unlikely to produce enough mitral valvular deformity to produce stenosis that dilates the left atrium."
a[44] = f + "(D) CORRECT. This can lead to rheumatic mitral stenosis with left atrial enlargement."
a[45] = f + "(E) Incorrect. Amyloid can be found in endocardium and myocardium, but it is best known as a cause for an infiltrative cardiomyopathy."
a[46] = f + "(A) Incorrect. Libman-Sacks endocarditis is associated with systemic lupus erythematosus."
a[47] = f + "(B) Incorrect. Scleroderma is not typically associated with an endocarditis."
a[48] = f + "(C) CORRECT. Patients with systemic lupus erythematosus can develop Libman-Sacks endocarditis, but the vegetations are never large and they rarely embolize, so the endocarditis is not clinically significant in most cases. She probably has a fibrinous pericarditis as a result of uremia from renal failure."
a[49] = f + "(D) Incorrect. ANCA-associated granulomatous vasculitis uncommonly involves the heart and does not involve the endocardium or pericardium."
a[50] = f + "(E) Incorrect. This is related to nonbacterial thrombotic (marantic) endocarditis, which can result from a hypercoagulable state that is a paraneoplastic syndrome (Trousseau syndrome)."
a[51] = f + "(A) Incorrect. The cardiac output tends to be reduced with tetralogy of Fallot. Systemic hypertension is not typically a feature of most congenital heart diseases."
a[52] = f + "(B) Incorrect. Weaker pulses in the lower extremities, compared to upper extremities, suggest coarctation of the aorta, not tetralogy of Fallot."
a[53] = f + "(C) Incorrect. Finger clubbing is more typically seen with chronic pulmonary diseases."
a[54] = f + "(D) Incorrect. Telangiectasias are small vascular prominences that are not generally associated with congenital heart diseases."
a[55] = f + "(E) CORRECT. The features are those of tetralogy of Fallot, which producces a right-to left shunt with cyanosis from mixing of right heart blood with left heart blood."
a[56] = f + "(A) Incorrect. If he develops cardiac failure as a consequence of his ischemic event, then he may in time develop pre-renal azotemia from diminished cardiac output."
a[57] = f + "(B) Incorrect. Hyponatremia is not typically a feature of ischemic heart disease."
a[58] = f + "(C) Incorrect. Alanine aminotransferase is an enzyme whose elevation is more specific for hepatocyte injury."
a[59] = f + "(D) CORRECT. The findings suggest an early ischemic event as part of a developing myocardial infarction. The troponin I can be elevated within a few hours, similar to the CK-MB."
a[60] = f + "(E) Incorrect. HDL cholesterol is the 'good' cholesterol that is more protective against ischemic heart disease."
a[61] = f + "(A) Incorrect. Dominant polycystic kidney disease is associated with intracranial aneurysms called 'berry aneurysms' which form in adult life in a location of weakness of the arterial wall."
a[62] = f + "(B) Incorrect. Diabetes mellitus is associated with accelerated atheroclerosis that involves the larger arteries, though hyaline arteriolosclerosis can occur in the kidneys."
a[63] = f + "(C) Incorrect. Hyperlipidemia is associated with atherosclerosis, not hyperplastic arteriolosclerosis."
a[64] = f + "(D) CORRECT. The small arteries of the kidney are affected by hyperplastic arteriolosclerosis. Malignant hypertension is often preceded by chronic hypertension that leads to left ventricular hypertrophy. Hypertension is a risk for CNS hemorrhage."
a[65] = f + "(E) Incorrect. This is medial calcific sclerosis and is seen in older persons in small to medium-sized muscular arteries. It produces no serious consequences."
a[66] = f + "(A) Incorrect. Dehisence, when the suture margin comes loose, is a rare complication that manifests soon after the surgery."
a[67] = f + "(B) Incorrect. Any abnormal endocardial surface is subject to a risk for infection and development of infective endocarditis, but this is not the reason to replace the valve after 5 to 10 years."
a[68] = f + "(C) Incorrect. Bioprostheses are not subject to component failure. The mechanical prosthesis now used are also quite reliable. A certain model of valve was 'recalled' some years ago because of the tendency of one component to break, and this type of valve is no longer used."
a[69] = f + "(D) CORRECT. The bioprosthesis has the advantage of not requiring anticoagulation, but it does not wear well with time, and typically must be replaced within 5 to 10 years when its leaflets undergo progressive calcification leading to stenosis."
a[70] = f + "(E) Incorrect. Patients with mechanical prostheses are given anticoagulant therapy, but persons with bioprostheses do not need this medication."
a[71] = f + "(A) CORRECT. The most common cause for a primary myocarditis is a virus (such as Coxsackie virus). Viral myocarditis can be a cause for sudden death in a young person."
a[72] = f + "(B) Incorrect. <I>Candida</I> myocarditis is rare. It may occur in some immunocompromised patients."
a[73] = f + "(C) Incorrect. Fungal infections of the heart are rare. They are usually seen in immunocompromised patients."
a[74] = f + "(D) Incorrect. S. viridans is a cause for bacterial endocarditis. A myocarditis could be produced from septic emboli from vegetations, but this is not common."
a[75] = f + "(E) Incorrect. S. aureus is a cause for bacterial endocarditis. A myocarditis could be produced from septic emboli from vegetations, but this is not common."
a[75.1] = f + "(F) Incorrect. Cytomegalovirus is a rare cause for myocarditis, seen in immunocompromised persons."
a[75.2] = f + "(G) Incorrect. Group A streptococcal infections are a cause for rheumatic fever, which may produce a myocarditis with granulomatous inflammation characterized by Aschoff nodules."
a[76] = f + "(A) Incorrect. The CK-MB is typically elevated with ischemic heart disease, which would be unusual at his age."
a[77] = f + "(B) CORRECT. The history points to infectious endocarditis and acute congestive heart failure. <I>Staphylococcus aureus</I> and <I>Pseudomonas aeruginosa</I> are the most likely organisms to be found with a history of injection drug use."
a[78] = f + "(C) Incorrect. A cholesterol in this range could be seen with heterozygous familial hypercholesterolemia, which would be unlikely to manifest with ischemic heart disease at this age."
a[79] = f + "(D) Incorrect. His heart failure, if severe, could reduce cardiac output and lead to pre-renal azotemia if he survives."
a[80] = f + "(E) Incorrect. An autoimmune disease such as systemic lupus erythematosus can lead to non-infective endocarditis (Libman-Sacks endocarditis) in which there are small, non-destructive vegetations and no emboli."
a[81] = f + "(A) Incorrect. Rib notching is a rare finding that can be seen with post-ductal coarctation of the aorta."
a[82] = f + "(B) Incorrect. There is upward ballooning of a mitral leaflet with prolapse, due to attenuated chordae tendineae. (Note: a VSD sometimes becomes closed when a tricuspid leaflet adheres to the opening)."
a[83] = f + "(C) CORRECT. The left-to-right shunt eventually leads to pulmonary hypertension and reversal of the shunt (Eisenmenger complex)."
a[84] = f + "(D) Incorrect. Congenital heart disease is, in general, not a risk for ischemic heart disease."
a[85] = f + "(E) Incorrect. The defect is between the ventricular chambers and not connected to the pericardial sac."
a[86] = f + "(A) Incorrect. The tricuspid valve is not often affected. When it is, the mitral and aortic valves are also affected, too."
a[87] = f + "(B) Incorrect. The mitral valve is the most common valve to be involved. The pulmonic valve is almost never involved."
a[88] = f + "(C) Incorrect. The aortic valve is the second most common valve to be involved. The pulmonic valve is almost never involved."
a[89] = f + "(D) Incorrect. The left side of the heart is involved far more commonly than the right with rheumatic heart disease."
a[90] = f + "(E) CORRECT. She has chronic rheumatic valvulitis with scarring associated with rheumatic heart disease. If the tricuspid valve is involved, then the mitral and aortic are probably involved as well. The most common single valve involved is the mitral."
a[91] = f + "(A) Incorrect. An elevation of the ASO titer suggests a recent streptococcal infection that might be associated with rheumatic fever. The infection, typically a pharyngitis, is gone by the time the ASO titer is elevated and the cardiac lesions, including myocarditis, are present."
a[92] = f + "(B) Incorrect. This level of cholesterol could be associated with familial hypercholesterolemia and risk for ischemic heart disease, even at a young age. This does not explain the fever."
a[93] = f + "(C) CORRECT. She has findings that suggest myocarditis, which can have features of cardiomyopathy. One of the most likely organisms is Coxsackie B virus."
a[94] = f + "(D) Incorrect. Viridans group of streptococcus is best known as a causative organism for subacute endocarditis, and valvular vegetations are present with forms of infective endocarditis."
a[95] = f + "(E) Incorrect. An antineutrophil cytoplasmic autoantibody can be detected with vasculitis, typically microscopic polyangiitis or ANCA-associated granulomatous vasculitis."
a[96] = f + "(A) Incorrect. Spherocytosis can lead to a mild hemolytic anemia that stresses the heart somewhat to produce mild hypertrophy."
a[97] = f + "(B) Incorrect. An iron deficiency anemia in an adult could chronically lead to increased cardiac output. If severe enough, there could be a high-output cardiac failure. The heart will tend to enlarge somewhat. This does not explain his arthritis or hyperglycemia, though."
a[98] = f + "(C) Incorrect. An increased sed rate is a non-specific indicator of inflammation somewhere in the body."
a[99] = f + "(D) Incorrect. Anti-centromere antibody can be detected with sclerodema, which can produce cardiac findings resembling a cardiomyopathy, but hyperglycemia and joint problems are not part of scleroderma."
a[100] = f + "(E) CORRECT. He has findings of a cardiomyopathy with right and left heart failure. Hereditary hemochromatosis can produce iron deposition in visceral organs, including the heart. The serum ferritin is a good indicator of body iron stores. Hemochromatosis affects the pancreas as well, leading to diabetes mellitus. Deposition of iron in joints leads to arthritis. The onset of disease is typically in the 40's in males and 60's in females."
a[101] = f + "(A) Incorrect. A pericarditis can produce pain, but not typically knife-like and not suddenly."
a[102] = f + "(B) CORRECT. This is a classic history for an aortic dissection. A tear in the aortic intima is followed by dissection of blood outward, often to the thoracic cavity, with fatal hemothorax. The risk factors in most adults include atherosclerosis and hypertension. In Marfan syndrome, the risk for aortic dilation and dissection results from cystic medial necrosis, but this occurs at a much younger age."
a[103] = f + "(C) Incorrect. Infective endocarditis is not typically associated with chest pain, unless a septic embolus occludes a coronary artery."
a[104] = f + "(D) Incorrect. Cardiomyopathies are not typically associated with chest pain."
a[105] = f + "(E) Incorrect. The pain of a myocardial infarction more typically is substernal and crushing, with radiation to the arm, but an MI needs to be ruled out."
a[106] = f + "(A) Incorrect. IHSS is a rare cause for a hypertrophic cardiomyopathy, and it occurs in adults."
a[107] = f + "(B) Incorrect. This condition is manifested at birth. If the hypoplasia is not severe, the baby may survive."
a[108] = f + "(C) Incorrect. The preductal form seen in neonates is severe and usually accompanied by a patent ductus arteriosus."
a[109] = f + "(D) CORRECT. The most common cardiac defect is a VSD. The baby may first become symptomatic when the pulmonary arteries dilate after the first month of life and the shunting from left-to-right increases."
a[110] = f + "(E) Incorrect. Although a bicuspid valve is present at birth, it functions fairly well. It calcifies and malfunctions in later adult life."
a[111] = f + "(A) Incorrect. Both the right and the left heart are typically involved with a cardiomyopathy, and right-sided failure would lead to peripheral edema."
a[112] = f + "(B) CORRECT. Although bicuspid aortic valves are present from birth, they do not manifest with significant calcification and stenosis until later adult life. The lack of peripheral edema points to a left-sided cause for congestive failure."
a[113] = f + "(C) Incorrect. Right-sided failure from tricuspid involvement with endocarditis would lead to peripheral edema."
a[114] = f + "(D) Incorrect. This most often results in abrupt onset of shock and/or chest pain."
a[115] = f + "(E) Incorrect. Amyloidosis produces a restrictive type of cardiomyopathy that typically involves both right and left heart."
a[116] = f + "(A) CORRECT. This history points to an infective endocarditis. A common risk factor for infective endocarditis is intravenous drug use."
a[117] = f + "(B) Incorrect. He does not have rheumatic disease."
a[118] = f + "(C) Incorrect. He does not have a pheochromocytoma."
a[119] = f + "(D) Incorrect. He does not have a viral myocarditis."
a[120] = f + "(E) Incorrect. He does not have an acute myocardial infarction. The valvular disease does not necessarily involve the adjacent myocardium."
a[121] = f + "(A) Incorrect. This is often idiopathic."
a[122] = f + "(B) CORRECT. Such cancers can be associated with a hypercoagulable state (Trousseau's syndrome) with formation of marantic cardiac valvular vegetations."
a[123] = f + "(C) Incorrect. Fibrinous pericarditis is most often seen with renal failure and uremia. It can also occur with myocardial infarction and with acute rheumatic fever."
a[124] = f + "(D) Incorrect. This is an uncommon idiopathic process in children. The left ventricle is involved more than the right by deposition of a thick collagen layer that interferes with contractility."
a[125] = f + "(E) Incorrect. Patients with advanced cancer often have a reversal of atherosclerotic lesions."
a[126] = f + "(A) Incorrect. Amyloidosis can lead to a restrictive (infiltrative) cardiomyopathy with more gradual onset of congestive heart failure (Note: under anesthesia, cardiac amyloidosis can lead to intractable arrhythmias)."
a[127] = f + "(B) CORRECT. Atrial myxomas are more often on the left. Though benign, they can occlude the mitral valve and produce sudden loss of cardiac output. They may embolize small portions of themselves or thrombus forned over their surface."
a[128] = f + "(C) Incorrect. A caseous pericarditis can resolve to a constrictive pericarditis, and syncopal episodes are not likely with this condition."
a[129] = f + "(D) Incorrect. Mitral prolapse can be a sudden event, though most often there is minimal symptomatology."
a[130] = f + "(E) Incorrect. Her total cholesterol, at least, does not indicate a risk for ischemic heart disease, and her heart is not enlarged."
a[131] = f + "(A) Incorrect. Coarctation does not lead to cyanosis."
a[132] = f + "(B) Incorrect. Tetralogy leads to a right-to-left shunt."
a[133] = f + "(C) CORRECT. This is the infamous 'paradoxical embolus' from right to left. This can only happen if there is a defect that allows passage from right-to left. This can happen across a patent foramen ovale. In this case, the pulmonary hypertension suggests that there may have been a shunt persistent for a long time--a so-called Eisenmenger complex. An atrial or a ventricular septal defect can provide the shunt."
a[134] = f + "(D) Incorrect. This is usually part of tetralogy of Fallot, which has a right-to-left shunt from birth."
a[135] = f + "(E) Incorrect. This is just a malposition of the heart, with the appropriate connections in place and no shunts."
a[136] = f + "(A) CORRECT. This finding has been associated with sudden death and cocaine use. It is thought that it may be mediated by high norepinephrine levels."
a[137] = f + "(B) Incorrect. Though lymphocytes may be present, they are seen less frequently and prominently than contraction band necrosis."
a[138] = f + "(C) Incorrect. Myofiber disarray is a feature of hypertrophic cardiomyopathy."
a[139] = f + "(D) Incorrect. Though atherosclerotic changes can occur with cocaine use, thrombosis of coronaries is not frequent, because the vessels involved are usually smaller coronary branches."
a[140] = f + "(E) Incorrect. Myocardial rupture does not typically occur with cocaine use, because a large myocardial infarction is not usually found."
a[141] = f + "(A) Incorrect: A constrictive pericarditis is typically a complication of tuberculosis, not acute myocardial infarction."
a[142] = f + "(B) CORRECT. A primary reason for putting a patient with an acute myocardial infarction in hospital is to prevent arrhythmias."
a[143] = f + "(C) Incorrect. Heart failure following an acute myocardial infarction is not uncommon, but most often the left heart is most affected, with left heart failure leading to pulmonary congestion and edema. Over time, left heart failure may lead to right heart failure which, if severe, may lead to profound hepatic congestion with centrilobular necrosis."
a[144] = f + "(D) Incorrect. Mural thrombi can form and embolize following acute myocardial infarction, but this is more likely to happen days to weeks to months later."
a[145] = f + "(E) Incorrect. This is a potential complication with a transmural acute myocardial infarction that happens from 3 to 7 days following the initial ischemic event."
a[146] = f + "(A) Incorrect. Collagenization occurs with healing weeks to months following an acute myocardial infarction, and rupture at this point is highly unlikely"
a[147] = f + "(B) Incorrect. Lymphocytic infiltrates are typical for a viral myocarditis, not myocardial infarction"
a[148] = f + "(C) Incorrect. Amyloidosis of the heart leads to a restrictive cardiomyopathy, not to infarction, and rupture does not occur"
a[149] = f + "(D) CORRECT. He has had an acute myocardial infarction complicated by rupture. This is a typical complication about 3 to 5 days following the onset. 75% arterial narrowing is the point at which coronary occlusion becomes very serious."
a[150] = f + "(E) Incorrect. Edema and loss of cross striations would be seen in the first day of an acute myocardial infarction, but rupture at this point is unlikely."
a[151] = f + "(A) Incorrect. This congenital condition is incompatible with life."
a[152] = f + "(B) CORRECT. This acquired condition can lead to valvular deformity that predisposes to infective endocarditis."
a[153] = f + "(C) Incorrect. Amyloidosis involves the myocardium, not the valves and is not a risk for infective endocarditis. It is imperative when infective endocarditis is suspected that an organism be identified and appropriate antibiotic therapy given to reduce the high mortality rate of this condition."
a[154] = f + "(D) Incorrect. Ischemic heart disease involves the myocardium and not the valves directly, so infection is not a typical complication."
a[155] = f + "(E) Incorrect. Cardiomyopathies are myocardial diseases that can lead to cardiac enlargement and/or hypertrophy with heart failure, but are typically not complicated by infection."
a[156] = f + "(A) Incorrect. Mitral ring calcification is rarely of functional consequence and is not related to an atherogenic diet."
a[157] = f + "(B) CORRECT. This is a complication of myocardial infarction. The incidence of MI is increased with an atherogenic diet."
a[158] = f + "(C) Incorrect. This is typically a complication of mitral stenosis with rheumatic heart disease."
a[159] = f + "(D) Incorrect. Most thoracic aortic aneurysms are a consequence of cardiovascular syphilis."
a[160] = f + "(E) Incorrect. Most aortic stenosis is a complication of bicuspid valves or senile calcific aortic stenosis unrelated to diet."
a[161] = f + "(A) CORRECT. These are classic findings for temporal arteritis, the most typical involvement with giant cell arteritis. Corticosteroid therapy typically produces a diminution in the symptoms. Biopsy of the artery can remove the offending site of inflammation and relieve symptoms (don't worry--there are collateral branches). Not treating this condition puts the patient at risk for involvement of other branches of the external carotid artery, the worst of which would be the ophthalmic branch. The elevation of the sed rate is way out of proportion to the extent and amount of inflammation in this one arterial segment."
a[162] = f + "(B) Incorrect. Rheumatoid arthritis is not typically associated with an arteritis."
a[163] = f + "(C) Incorrect. A low HDL cholesterol is a risk for atherosclerosis, but atherosclerosis does not produce significant arterial inflammation. Instead, clinical problems result from narrowing of the lumen."
a[164] = f + "(D) Incorrect. Anti-ds-DNA is very specific for systemic lupus erythematosus, a condition that can be associated with vasculitis caused by antigen-antibody complexes. Vasculitis with SLE is more widespread than giant cell arteritis and typically involves smaller arteries."
a[165] = f + "(E) Incorrect. Anti-neutrophil cytoplasmic autoantibody can be seen most often with microscopic polyangiitis or ANCA-associated granulomatous vasculitis. The pANCA is somewhat more common with polyarteritis."
a[166] = f + "(A) Incorrect. Rheumatic heart disease is best known for causing valvular deformities, most often of the mitral valve, but sometimes the mitral and aortic, or just the aortic valve, and rarely the tricuspid valve."
a[167] = f + "(B) Incorrect. A viral myocarditis can be the cause for sudden death, but there is myocyte necrosis with interstitial infiltrates of lymphocytes in all chambers."
a[168] = f + "(C) Incorrect. SLE is best known to cause a Libman-Sacks endocarditis. Pericarditis with effusions is also possible with autoimmune diseases."
a[169] = f + "(D) CORRECT. Myofiber disarray is the key feature of hypertrophic cardiomyopathy, an uncommon condition. The abnormal myocardium can be the focus for development of arrhythmias."
a[170] = f + "(E) Incorrect. Patients with diabetes mellitus are more likely to develop severe coronary atherosclerosis and subsequent myocardial ischemic damage."
a[171] = f + "(A) Incorrect. There is endocardial sclerosis of the right ventricular endocardium with carcinoid heart syndrome."
a[172] = f + "(B) CORRECT. The valve leaflet can balloon upward. This condition can be associated with Marfan's syndrome."
a[173] = f + "(C) Incorrect. Acute rheumatic fever produces small verrucous valvular vegetations. Chronic rheumatic changes include thickening and shortening of chordae tendineae."
a[174] = f + "(D) Incorrect. The large friable vegetations of infective endocarditis can lead to valvular destruction."
a[175] = f + "(E) Incorrect. There may be valve prolapse, but from rupture of a papillary muscle."
a[176] = f + "(A) Incorrect. Macrophages begin to appear at the end of the first week with an MI."
a[177] = f + "(B) CORRECT. This is an initial change as the myocardial fibers begin to die."
a[178] = f + "(C) Incorrect. Neutrophils begin to infiltrate the myocardium after the first day of an MI."
a[179] = f + "(D) Incorrect. Granulation tissue begins to form as the MI heals."
a[180] = f + "(E) Incorrect. Collagen is deposited in the healing phase of an MI."
a[181] = f + "(A) Incorrect. In general, persons with chronic alcoholism have less atherosclerosis."
a[182] = f + "(B) Incorrect. There is no increased risk for myocarditis in alcoholism."
a[183] = f + "(C) Incorrect. Alcoholism is not a risk factor for amyloidosis of any kind."
a[184] = f + "(D) Incorrect. Nonbacterial thrombotic endocarditis (NBTE) is a form of non-infective endocarditis that can occur in severely debilitated patients, though hypercoagulability that contributes to this process is not favored by chronic liver disease."
a[185] = f + "(E) CORRECT. The cardiomyopathy of chronic alcohol abuse has a dilated or congestive appearance."
a[186] = f + "(A) Incorrect. Hypercholesterolemia is a risk factor for atheroscclerosis, which most often affects the abdominal aorta, leading to aneurysm formation. Mural thrombus is prone to develop when blood flow patterns are abnormal, as in an aneurysm."
a[187] = f + "(B) Incorrect. Marfan syndrome leads to cystic medial necrosis, not endaortitis, and appears earlier in life."
a[188] = f + "(C) Incorrect. Classic polyarteritis nodosa most often involves small to medium-sized muscular arteries, including renal and mesenteric arteries, and sometimes veins, with necrosis and microaneurysm formation."
a[189] = f + "(D) Incorrect. Takayasu arteritis can involve the aorta, particularly the arch, and branches such as coronary and renal arteries with granulomatous inflammation, aneurysm formation, and dissection. It appears at a much earlier age."
a[190] = f + "(E) CORRECT. T. pallidum is the organism that causes syphilis. The endaortitis of the vasa vasora affects the media of the aorta, leading to buckling of the intimal surface in a 'tree bark' pattern, and aneurysmal dilation, including the aortic root, causing aortic regurgitation. This happens decades following initial infection."
a[190.1] = f + "(F) Incorrect. ANCA-associated granulomatous vasculitis involves small arteries, veins, and capillaries with mixed inflammation, necrotizing and non-necrotizing granulomatous inflammation withgeographic necrosis surrounded by palisading epithelioid macrophages and giant cells."
a[191] = f + "(A) Incorrect. Even a large VSD should not be fatal in such a short time."
a[192] = f + "(B) CORRECT. The poor outcome so soon after birth suggests a severe defect, and lack of sufficient left heart to provide appropriate cardiac output can explain these findings. There can be varying degrees of hypoplasia which determine how long the child survives."
a[193] = f + "(C) Incorrect. If a transposition is present with no shunt, then any survival is not possible, as the systemic and pulmonary circulations would be completely separate."
a[194] = f + "(D) Incorrect. ASD's create a shunt, but the lack of a significant pressure difference between left and right atrium means that cardiac function is not severely affected."
a[195] = f + "(E) Incorrect. Group B strep infections may produce fetal or neonatal loss, but do not typically produce congenital heart defects. However, congenital rubella in the first trimester can lead to cardiac defects."
a[196] = f + "(A) CORRECT. The uremia leads to exudation of fibrin onto the epicardial and pericardial surfaces."
a[197] = f + "(B) Incorrect. This is more typical of tuberculosis or metastatic tumor."
a[198] = f + "(C) Incorrect. This is not common but can occur with spread of infection from lung or mediastinum."
a[199] = f + "(D) Incorrect. This is more typical for collagen vascular diseases."
a[200] = f + "(E) Incorrect. This is a late complication of tuberculous pericarditis. It may also follow cardiac surgery or radiation to the chest."
a[201] = f + "(A) Incorrect. This is one of the Jones' criteria for acute rheumatic fever."
a[202] = f + "(B) CORRECT. Strains of streptococci which cause acute rheumatic fever are not the same as the strains which can produce a post-streptococcal glomerulonephritis. Libman-Sacks endocarditis is most often seen in patients with autoimmune diseases such as systemic lupus erythematosus."
a[203] = f + "(C) Incorrect. This is one of the Jones' criteria for acute rheumatic fever."
a[204] = f + "(D) Incorrect. This is one of the Jones' criteria for acute rheumatic fever."
a[205] = f + "(E) Incorrect. This is one of the Jones' criteria for acute rheumatic fever."
a[206] = f + "(A) Incorrect. Serous or fibrinous pericarditis is more common with SLE and other autoimmune diseases."
a[207] = f + "(B) Incorrect. The pericarditis of uremia is typically fibrinous."
a[208] = f + "(C) Incorrect. Rheumatic fever is associated with a fibrinous pericarditis."
a[209] = f + "(D) CORRECT. Pericardial tumor and tuberculosis are the typical causes for a hemorrhagic pericarditis."
a[210] = f + "(E) Incorrect. This may lead to a fibrinous pericarditis."
a[211] = f + "(A) Incorrect. Hypertension is not typically related to any of the arteritides."
a[212] = f + "(B) CORRECT. The pressure load on the left ventricle leads to left venricular hypertrophy, but eventually the heart can no longer compensate and there is left heart failure, which leads to pulmonary congestion and edema."
a[213] = f + "(C) Incorrect. Hyperplastic arteriolosclerosis can be seen in some cases of malignant hypertension. However, this is an uncommon complication."
a[214] = f + "(D) Incorrect. Some cardiac dilation may occur along with hypertrophy from hypertension, and this could cause minimal mitral insufficiency, but the tricuspid valve is on the right, and would only be affected after the right heart began to fail."
a[215] = f + "(E) Incorrect. Hypertension does not lead to myocarditis."
a[216] = f + "(A) Incorrect. Aortic dissection is a medical emergency associated with severe pain. Patients go into shock."
a[217] = f + "(B) Incorrect. These findings suggest embolic disease, which could come from mural thrombus overlying an area of infarction, but persons with malignant neoplasms tend to have regression of atherosclerosis."
a[218] = f + "(C) Incorrect. Hypertrophic cardiomyopathy is a process that is not associated with malignancies and is not typically accompanied by embolic events."
a[219] = f + "(D) Incorrect. Metastases to the heart are most often epicardial and can produce hemorrhagic pericarditis (without tamponade). Embolic events do not occur."
a[220] = f + "(E) CORRECT. A He has both venous and arterial thromboembolic disease that suggests Trousseau syndrome. Non-bacterial thrombotic endocarditis (NBTE) is seen with this paraneoplastic condition. Though the small vegetations are bland, they often embolize, in this case in the systemic circulation to spleen and kidney. The highest rate of Trousseau syndrome occurs with high grade gliomas--about 25% of patients."
a[221] = f + "(A) Incorrect. Alcoholic cardiomyopathy, like dilated cardiomyopathies, involves all four chambers, and he should have signs and symptoms of left as well as right heart failure."
a[222] = f + "(B) Incorrect. A viral myocarditis tends to affect the whole heart, leading to right and left-sided failure, but the process occurs over days to weeks, not months."
a[223] = f + "(C) Incorrect. A bicuspid aortic valve tends to calcify in older adults, leading to stenosis and obstruction to left ventricular outflow with signs and symptoms of left heart failure."
a[224] = f + "(D) Incorrect. Constrictive pericarditis leads to diminished cardiac motion with diminished diastolic filling, and the heart is not increased in size."
a[225] = f + "(E) CORRECT. The findings suggest a predominantly right-sided congestive heart failure, which would be characteristic for cor pulmonale. Pulmonary hypertension most often results from obstructive or restrictive lung diseases."