PANCE Cardiovascular System 3 — Questions and Answers
Question 1: A 60-year-old woman with atrial fibrillation has a CHA₂DS₂-VASc score of 4. She has no contraindications. Which anticoagulation is preferred?
- Aspirin 325 mg daily
- Warfarin with target INR 2-3
- Direct oral anticoagulant (DOAC) (Correct answer)
- Clopidogrel
Correct answer: Direct oral anticoagulant (DOAC)
DOACs are preferred over warfarin for non-valvular atrial fibrillation due to superior efficacy, safety, and convenience without routine INR monitoring.
Question 2: A patient develops hypotension, bradycardia, and diaphoresis minutes after inferior wall STEMI. Which artery is most likely occluded?
- Left anterior descending artery
- Left circumflex artery
- Right coronary artery (Correct answer)
- Left main coronary artery
Correct answer: Right coronary artery
The right coronary artery supplies the inferior wall, SA node, and AV node; its occlusion causes inferior STEMI with bradycardia and hypotension.
Question 3: Which physical exam finding is pathognomonic for constrictive pericarditis?
- Pulsus paradoxus >10 mmHg
- Kussmaul sign (Correct answer)
- Friction rub
- S3 gallop
Correct answer: Kussmaul sign
Kussmaul sign (paradoxical rise in JVP with inspiration) is the hallmark of constrictive pericarditis due to impaired right heart filling against a rigid pericardium.
Question 4: A 50-year-old man with dilated cardiomyopathy and EF of 25% is on optimal medical therapy. Which device therapy reduces mortality most significantly?
- Biventricular pacemaker (CRT) alone
- Implantable cardioverter-defibrillator (ICD) (Correct answer)
- Permanent pacemaker
- Wearable defibrillator vest
Correct answer: Implantable cardioverter-defibrillator (ICD)
ICD implantation reduces sudden cardiac death in patients with EF ≤35% and symptomatic heart failure on optimal medical therapy per MADIT-II and SCD-HeFT trials.
Question 5: A 35-year-old woman develops sudden-onset severe headache and is found to have markedly elevated blood pressure (240/130 mmHg) with papilledema. Which agent should be avoided?
- Nicardipine IV
- Labetalol IV
- Nitroprusside IV (Correct answer)
- Hydralazine IV
Correct answer: Nitroprusside IV
Nitroprusside is metabolized to cyanide and can increase intracranial pressure, making it problematic in hypertensive emergency with neurologic involvement.
Question 6: A 78-year-old man has an ECG showing a delta wave and short PR interval. He presents with palpitations and rapid irregular rhythm. Which drug is CONTRAINDICATED?
- Procainamide
- Amiodarone IV (cautiously)
- Adenosine (Correct answer)
- DC cardioversion
Correct answer: Adenosine
Adenosine blocks the AV node in Wolff-Parkinson-White with atrial fibrillation, forcing conduction through the accessory pathway and potentially causing ventricular fibrillation.
Question 7: A patient presents with fever, new-onset aortic regurgitation murmur, and splinter hemorrhages. Blood cultures grow viridans streptococci. Which is the most likely portal of entry?
- IV drug use
- Urinary tract infection
- Dental procedure (Correct answer)
- Skin infection
Correct answer: Dental procedure
Viridans streptococci are oral flora and the most common cause of native valve endocarditis following dental procedures.
PANCE Cardiovascular System 3
A 60-year-old woman with atrial fibrillation has a CHA₂DS₂-VASc score of 4.
She has no contraindications.
Which anticoagulation is preferred?