D. ST Elevations in Lead V4R
D. ST Elevations in Lead V4R
D. ST Elevations in Lead V4R
Her
EKG reveals ST elevation in the inferior leads. Which of the following findings is most likely to
suggest the presence of an accompanying right ventricular infarct?
A. Negative T wave in V4R
B. ST elevations in lead I
C. ST elevations lead II > III
D. ST elevations in lead V4R
E. ST depression in V4R
3. Causes of pathologic Q waves not secondary to myocardial infarction include all of the
following except:
A. Amyloidosis
B. Dilated cardiomyopathy
C. Wolff-Parkinson-White syndrome
D. Cardiac transplant
E. Acute myocarditis
4. You are consulted on a 21-year-old female who requires a cardiac workup following a small
right middle cerebral artery stroke. She has no other significant past medical history. On
questioning, she admits to having a history of breathlessness with maximal exertion for as
long as she can remember. All of the following findings may be observed on her
electrocardiogram except:
A. Leftward QRS axis
B. Left bundle branch block (LBBB)
C. Atrial fibrillation
D. Negative P waves in II, III, aVF
E. Presence of an rsR′ in V1 with a QRS < 0.12 seconds
7. A 65-year-old male is referred to you for evaluation of possible coronary artery disease. He
gives a 4-week history of chest discomfort with climbing two flights of stairs, where he had
previously been able to climb several flights without difficulty. He denies any dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, or syncope. Two weeks ago, he was started on
isosorbide mononitrate 30 mg po daily, metoprolol 25 mg po twice daily, and aspirin 80 mg
po daily by his primary care physician. Physical exam is within normal limits. You plan to
perform an exercise stress test. Which of the following sets of instructions is false?
A. Instruct the patient to hold metoprolol for at least 24 hours prior to the test
B. Instruct the patient to avoid vigorous exercise the day of the test
C. Instruct the patient to hold his morning dose of isosorbide mononitrate the day of the test
D. Instruct the patient to continue all medications
E. Instruct the patient to avoid caffeine in the event that a vasodilator stress will be
performed at the same time
8. A 48-year-old female presents to the emergency department with central chest pain and
dyspnea that now occurs after walking one block. The chest pain began six months ago, but
the symptoms have become more frequent and occur with even less exertion. She describes
an episode of syncope without prodrome. Her family history is significant for a brother
having undergone a cardiac surgery at age 52. A systolic ejection click with an associated
systolic murmur is noted on exam. Serial troponins are negative. What is the next best
course of action?
A. Book an exercise stress test
B. Proceed with transthoracic echocardiography
C. Proceed with coronary angiography
D. Consult cardiac surgery
E. Start a beta blocker and discharge home with follow-up in clinic
10. Which of the following statements about exercise stress testing is false?
A. The formula MPHR = 220 – age results in an underestimation of maximum heart rate,
particularly in older patients
B. The formula MPHR = 220 – age was originally developed to be used for patients’ exercise
prescriptions
C. The exercise stress test may be terminated when the maximal predicted heart rate
reaches 85%
D. Achieving either maximum effort or an ischemic endpoint is crucial for exercise testing
performed with or without imaging
E. The maximum predicted heart rate is best achieved by using the formula MPHR = 208 –
0.7 × age
11. A 42-year-old man with diabetes mellitus type II and dyslipidemia is referred for an exercise
stress test from the emergency department. He began to complain of dull left shoulder pain
2 weeks prior to presentation. The pain has worsened in the last few days, and it is
precipitated by walking up stairs. He remarks that he thinks he may have hurt his shoulder
during snow shoveling 2 weeks ago. A physical exam reveals a blood pressure of 138/78 HR
84 regular, oxygen saturation 98% on room air, and respiratory rate of 14. He is afebrile.
Normal heart sounds are auscultated, and no murmurs are present. Serial troponins are
negative.
In this patient, all of the following resting electrocardiographic findings may cause
reconsideration of an exercise stress test as the primary investigation, except:
A. Presence of preexcitation
B. Presence of an LBBB
C. Presence of a paced rhythm
D. Atrial fibrillation with a rapid ventricular response
E. Intraventricular conduction delay
12. A 42-year-old man with diabetes mellitus type II and dyslipidemia is referred for an exercise
stress test from the emergency department. He began to complain of dull left shoulder pain
2 weeks prior to presentation. The pain has worsened in the last few days, and it is
precipitated by walking up stairs. He remarks that he thinks he may have hurt his shoulder
during snow shoveling 2 weeks ago. A physical exam reveals a blood pressure of 138/78 HR
84 regular, oxygen saturation 98% on room air, and respiratory rate of 14. He is afebrile.
Normal heart sounds are auscultated, and no murmurs are present. Serial troponins are
negative.
All of the following parameters should usually prompt exercise stress test termination
except:
A. 1 mm ST elevation in the anterior precordial leads
B. A decrease in the systolic blood pressure by 10 mm Hg
C. Patient would like to terminate the test
D. Isolated premature ventricular contractions
E. Mobitz type 1 second-degree heart block
13. A 42-year-old man with diabetes mellitus type II and dyslipidemia is referred for an exercise
stress test from the emergency department. He began to complain of dull left shoulder pain
2 weeks prior to presentation. The pain has worsened in the last few days, and it is
precipitated by walking up stairs. He remarks that he thinks he may have hurt his shoulder
during snow shoveling 2 weeks ago. A physical exam reveals a blood pressure of 138/78 HR
84 regular, oxygen saturation 98% on room air, and respiratory rate of 14. He is afebrile.
Normal heart sounds are auscultated, and no murmurs are present. Serial troponins are
negative.
Which of the following results would constitute the worst prognosis?
A. 1 mm of slow upsloping ST depression at 5 METS, with resolution upon termination of
exercise
B. 0.5 mm of slow downsloping ST depression at 7 METS, with persistence into 2 minutes of
recovery
C. 1.5 mm of horizontal ST depression at 5 METS, with resolution upon termination of
exercise
D. 1.5 mm of horizontal ST depression at 5 METS, with persistence into 2 minutes of
recovery
E. 1.5 mm of downsloping ST depression at 7 METS, with resolution upon termination of
exercise
14. A 42-year-old man with diabetes mellitus type II and dyslipidemia is referred for an exercise
stress test from the emergency department. He began to complain of dull left shoulder pain
2 weeks prior to presentation. The pain has worsened in the last few days, and it is
precipitated by walking up stairs. He remarks that he thinks he may have hurt his shoulder
during snow shoveling 2 weeks ago. A physical exam reveals a blood pressure of 138/78 HR
84 regular, oxygen saturation 98% on room air, and respiratory rate of 14. He is afebrile.
Normal heart sounds are auscultated, and no murmurs are present. Serial troponins are
negative.
Which of the following patients performing an exercise stress test would be identified as a
moderate risk for cardiovascular death or nonfatal myocardial infarction over 5 years follow-
up?
A. A 45-year-old male performs 7 minutes on EST, limited by chest pain with 2 mm ST
depressions during exercise in the inferior leads
B. A 55-year-old female performs 7 minutes on EST, and she stops due to fatigue with 1
mm of horizontal ST depressions into recovery in the anterior precordial leads
C. A 64-year-old female performs 8 minutes on EST, and she stops as a result of leg pain with
0.5 mm ST depressions in the inferior leads during exercise only
D. A 55-year-old female performs 4 minutes on EST, and she stops due to dyspnea, with 3
mm of horizontal ST depressions in the anterior precordial leads during exercise
E. A 70-year-old male performs 7 minutes on EST, limited by leg cramping, with no ST
deviation