MDE CVS 2010

1. Anterior tibial artery?
2. Most common site of DVT
3. as a pathologist, you must examine av bundle histologically. In which of the following tissue sample will you find the av bundle?

4. artery to the AV node arise from?
a. circumflex artery
b. RCA
c. right marginal
d. anterior interventricular
e. posterior interventricular

14. Congenital heart disease karena kegagalan arteriopulmonary septum tumbuh secara spiral?
a. left atrium
b. right strium
c. interatrial septum
d. muscular interventricular septum
e. membranous interventricular septum

untuk no 21-25: GAMBAR lapisan pembuluh darah arteri-vena
21. Endothelium
22. Internal elastic lamina
23. muscular layer
24. external elastic lamina
25. tunica adventitia

Untuk nomor 26-
26.endocardium mitral valve
27. endocardium ventricle
28. subendocardium

a.LDH
b.SGOT
c. DGBH
d. CKMB
e. Troponin
31.this test can assist in diagnosing reinfarction
32. this test is characteristically for qualitative test
33. remain 12th day post infarct
36. mass exam is better than activity exam

A. Mg
B. Na
C. Ca
D. Potassium
E. Cl
41. Fisiologis Ca antagonis
42. Jumlah yang banyak pada mineral ini dapat menyebabkan kontraksi otot
43. Paling banyak di extracellular
44. Coenzim
45. Kation paling banyak di intracellular

a. low sensitivity
b.low specificity
c. high sensitivity
d. high specificity
e. high sensitivity and high specificity
46. it is used as a screening test
47. it is used as a diagnostic test
48. if the result is negative, there is no disease
49. if the result is positive, there is a disease
50. it is only theoretical test

51. One of WHO diagnostic criteria for AMI
a. ECG
b. treadmill
c. X-Ray
d. Echocardiography
e. Cardiac perfusion

a. ECG
b. Treadmill
c. Chest X-Ray
d. Echocardiography
e. Cardiac perfusion scan
53. Check size of myocard damage
54. Test if ECG is failed to show abnormality
55. Measure size of heart

68. If HR = 90 bpm, EDV = 150, CO = 6.3 L/min, ESV ?
a. unknown
b. 220
c. 200
d. 80
e. 60

70. 1st heart sound
a. ventricular filling
b. closure aortic & pulmonary valve
c. vibration ventricular wall on systole
d. closure mitral & tricuspid valves
e. retrograde vena cava

71. 4th heart sound

104. heart auscultastion of ASD
a. wide split &fixed S2
B. narrow split S2
c. loud split S2
d. paradoxical split
e. normally splitting S2

124. A 24 y.o man goes to the atletic field. HE runs for 1 hour. Physiologic CVS changes?
a. decrease pulmonary arterial resistance
b. increase pulmonary arterial pressure
c. increase total peripheral resistance
d. decrease diastolic pressure
e. increase SV

128. symptom of large VSD?
Ans : poor feeding, rapid breathing

129. Cause of subacute IE?
a. S. epidermidis
b. S. Viridans
c. S. aureus

132. The most important cause of secondary pulmonary hypertension is…
a. chirosis of liver
b. scleroderma
c. pulmonary thromboembolism
d. COPD
e. Schistosomiasis

133. 31 years old woman come to ER: progressive dyspnea, no fever over 1 week. She has delivered spontaneously 4th baby 5 weeks ago. No health problem before except mild hypertension. Diagnosis dyspnea :
a. Dilated cardiomyopathy
b. Restrictive cardiomyopathy
c. Hypertrophy cardiomyopathy
d. Pulmonary embolism
e. Pulmonary infarction

136. Pasien dating ke ER dengan keluhan dyspnea on moderate activity. Ada thrill di apex. P2 accentuated. Diagnosis?
a. mitral regurgitation
b. mitral stenosis
c. aortic regurgitation
d. aortic stenosis
e. tricuspid stenosis

139. unstable angina is characterized by…
a. angina after exercise
b. angina relieve by sublingual nitrate
c. angina <10 minutes
d. first onset angina
e. angina relieved by rest

141. Thrombolytic paling tepat diberikan pada pasien?
a. ST depression
b. new bundle branch block
c. T inverted
d. non diagnose change
e. blocked atrioventricular

142. A patient w/ symptoms of AMI has ST segment depression of 2 mm on the ECG lead I&AVL, this may reflect
a. inferior wall infarction
b. anterior wall infarction
c. anteroseptal wall infarction
d. high lateral wall infarction
e. anterolateral wall infarction

145. Spironolactone
a. IV administration
d. water soluble potassium interfensi
e. reducing CHF

146. function of risk stratification in CAD?
a. looking for risk stratification
b. choosing 1st or secaondary prevention
c.
d.choosing appropriate treatment
e.

147. What is the following patient of heart failure who needs β-adrenergic bloacker
a. ?
b. class III NYCA heart failure
c. sinus rhythm + rate = 40 bpm
d. advance heart block
e. patient  depression

151. MoA amiodarone
a. blocking Na channel
b. blocking Ca channel
c. blocking K channel

152. Acute pericarditis…

153. ER  chest pain+fever ; pericardial friction rub; ↑ WBC + ESR
Acute pericarditis presentation?
a. pain onset crescendo
b. more comfortable in recumbence
c. abnormal S3 & S4
d. Pulmonary congestion in sever pericarditis
e. Rubs last hours to days

156. WOTF statement is true about physical finding in acute pericarditis?
a. Acute pericarditis produces retrosternal pain.
b. Pericardial friction rub is the hallmark of acute pericarditis.
c. Pericardial pain is almost always relieved by lying down.
d. Most pericardial friction rub are louder during expiration.
e. The friction rub is best heard while the patient is lying down.

157. PE cardiac tamponade:
a. arterial hypotension, wide pulse pressure
b.prominent basal rales and dyspnea
c. a rapid X descent, pulsus paradoxus, arterial hypotension
d. rapid X and Y descent, tachycardia
e. normal JVP, pulsus alternans
159. Pathophysiology of constrictive pericarditis :
a. Increased cardiac index of consequence of impaired filling
b. Normal EF and contraction
c. Ventricular filling occurs in every early diastole
d. Isovolumetric relaxation → increased period
e. …? Venous return during diastole ↑??

160. WTOF statement about pericardiocentesis is TRUE…
a. An anti-inflammatory agent is recommended prior to pericardiocentesis
b. Surgical intervention (pericardial window) usually better than percutaneous pericardiocentesis
c. size of effusion is well correlated w/ probability of successfully obtaining pericardial fluid
d. IV hydration should be initiated before threatened tamponade is diagnosed
e. pericardiocentesis especially useful in which a loculated effusion is present

162. patient present w/ systemic embolic event 1mo after MV replacement. For the past 1 week experience febrile. Blood culture, what organism?
a. S.viridans
B. S. aureus
c. Staphilococcus epidermidis
d. E. fecalis
e. Candida albicans

168. Thrombolytic therapy Is primarily indicated to patients with AMI whose ECG shows:
a. ST elevation
b. ST depression
c. T wave inversion
d. Pathologic Q wave
e. any ECG changes

171. definitive diagnosis CAD
a. coronary angiography
b. resting ECG
c. Exercise ECG
d. Cardiac enzyme
e. Echocardiography

172. factor most important in pulmonary hypertension in COPD
a. Loss small vessel inmost vascular regions
b. emphysema & lung destruction
c. pulmoany vasculature constriction due to hypoxia
d. ↑ CO from polycythemia
e. ↑ blood viscosity secondary to hypoxia

175. in the training phase a rehabilitation program following MI, a conditioning program is used to increase the physical work capacity. This conditioning program is one..
a. passively
b. passive active
c. assistive
d. actively
e. active resistive

176. in the training phase, target HR fot exercise training is:
a. 55-65% of maximal HR
b. 65-75% of maximal HR
c. 75-85% of maximal HR
d. 85-95% of maximal HR
e. 95-100% of maximal HR

194. Cardiac phenotypic changes result to alteration of cardiac cells metabolic rates, such as :
a. decrease calcium removal
b. increase cardiac contractility
c. decrease cardiac relaxation
d. decrease perfusion pressure
e. increase stiffness of the heart

?. Gangguan genetic metabolism mucopolysaccharides menyebabkan…
a. CHD
b. VHD
c. RHD

? Pulmonary vasodilator? Nitric Oxide

MDE CVS 2009

MDE CVS 2009
Nb : tmen2,nie ada bbrp jawaban yang fotokopiannya beda sendiri. Yang ada tanda tanya artinya ga yakin. Sori ya ga pake alasan,soalnya ngerjainnya buru2,klo bisa dicek sendiri sekalian belajar juga...:) klo masih banyak kekurangan mohon dimaafkan...-__-

1. D
2. E
3. C
4. D
5. C (sebenernya tepatnya letak mitral valve di posterior sternum costal 4)
6. E
7. D
8. E
9. C
10. D
11. E
12. B
13. C
14. E
15. A
16. ??? (mungkin low level HDL atau high level LDL)
17. B (ga ada soalnya tapi mungkin nanya ttg AST/ALT,liat di soal yg buku)
18. ??? (angkanya ga jelas,tapi cara ngitungnya CKMB/CK total. Satuannya jgn lupa disamain dulu  1 IU = 0.025 microgram)
19. C
20. B
21. C
22. B
23. A
24. D
25. B
26. D
27. C
28. E
29. F
30. E
31. C
32. C
33. C
34. A???
35. C
36. E
37. E
38. A
39 D
40. C
41. B
42. A
43. D
44. C???
45. E
46. D
47. D
48. A/C/D???
49. B???
50. E
51. A
52. D???
53. C
54. A???
55. C
56. D
57. B
58. E
59. B
60. D???
61. E
62. C/E
64. C
67. A
68. ??? (harusnya diffuse ST elevation & PR segment depression)
69. D???
71. C
73. C
74. C
75. B???
77. E
79. ???
80. D???
81. D
83. D
86. B
87. B
88. A
89. A
90. C
91. D
92. D
93. B
94. C
95. B
96. E
97. C
98. E
99. D
100. B
101. A/B
102. opening K+
103. D
104. B
105. E
106. A
107. A
108. C
109. A
110. A
111. B
112. A
118. C???
119. B???
120. A
121. B
124. D
125. B
126. A
127. D??
128. D
129. C
130. E
132. A
133. C
134. D
135. D
136. E
137. D
138. C
139. D
140. C
141. B
142. C???
143. C???
144. A
145. ???
157. B
158. A???
159. C
160. B
161. A
162. D
163. B
164. C
165. E
166. D
167. A
168. A???
169. B???
170. E???
171. D???
172. C???
173. ???
174. C???
175. C
176. E???
187. B
188. C
189. A
190. B
191. C???
192. D
193. B
194. B
195. B
196. D
197. B
198. E
199. D
200. B

MDE CVS 2005

1. Jawaban : B. Secundum defect
Alasan : Nelson hlm 1506
2. Jawaban : A. Widely fixed & split S2
Alasan : Nelson hlm 1506
3. Jawaban : D. The ductus arteriosus normally diverts 80% of RV output
Alasan : Lilly hlm 379
4. Jawaban : ???
Alasan : Kemungkinan A,soalnya opsi lain ga mungkin
5. Jawaban : B. VSDs may be associated with coarctation of aorta
Alasan : Nelson hlm 1508
6. Jawaban : ???
Alasan :
7. Jawaban : ???
Alasan :
8. Jawaban : C. TOF
Alasan : Lilly hlm 390-391
9. Jawaban : E. Premature closure of foramen ovale
Alasan : foramen ovale harusnya menutup setelah lahir bukan pada saat prenatal life
10. Jawaban : D. Coarctation of aorta
Alasan :Lilly hlm 389
11. Jawaban : D. TGA
Alasan : Lilly hlm 393
12. Jawaban : A. Atrial septal defect
Alasan : Lilly hlm 380-381
13. Jawaban : B. Hypoplasia of endocardial cushion
Alasan : Lilly hlm 380-381
14. Jawaban : D. The diatal part of 6th aortic arch
Alasan : Moore embryology hlm 361-365
15. Jawaban : A. Aortic regurgitation
Alasan : Lilly hlm 42
16. Jawaban :
Alasan : Most cases of congenital heart disease were thought to be multifactorial and result from a combination of genetic predisposition and environmental stimulus (nelson)
17. Jawaban : D. Arteries
Alasan : stretch receptor ada di aorta dan carotid sinus
18. Jawaban : C. Closure of foramen ovale due to increase pressure at left atrium
Alasan : yang lain kurang tepat
19. Jawaban : B. Period of isovolumic (isometric) contraction
Alasan : guyton hlm 107
20. Jawaban : D. Higher frequency
Alasan : Lilly hlm 32-33

21. d. TOF: aorta overriding, RV hypertrophy, VSD, pulmonary artery stenosis
22. A. berikut statement dari emedicine tentang VSD: “A measurement of LA and left ventricular (LV) diameters provides semiquantitative information about shunt volume. The size of the defect is often expressed in terms of the size of the aortic root. Defects that approximate the size of the aortic root are classified as large, those one third to two thirds of the diameter of the aorta are classified as moderate, and those less than one third of the aortic root diameter are classified as small”,
Pada defect lain, pada pemeriksaan defect, tidak ditemukan hubungan dengan aorta.
23. D. pada VSD terjadi shifting left to right  peningkatan volume yang ada di RV pulmonary left atrium  enlargement
Juga terdapat systemic insufficiency kalo VSD besar  stimulate Left ventricular enlargement. Jadi tidak ada keterlibatan right atrium
24. e. gambaran PDA adalah leftright shunt dengan adanya left side chambers enlargement dengan adanya prominent pulmonary vascular marking.
25. a. CTR: infant >= 50%; dewasa < 50%
26.
27.
28. bingung. S.Aureus dan S.viridans merupakan leading cause dari endocarditis pada pada pediatric pasien. S.aureus lebih sering pada kejadian tanpa adanya underlying disease, sedangkan s.viridans terjadi lebih sering setelah melakukan dental procedure.. jadi jawabannya antara a/b, tergantung nanti soal mintanya apa..
29.C. untuk prophylaxis antibiotic digunakan penicillin, tapi kalo alergi diaganti cephalixin or clindamycin or azithromycin
30. e. bisa karena infectious microorganism, autoimmune mediated cytotoxicit, cytokine damage. Tapi yang paling sering adalah virus (enterovirus ssRNA that include coxsackie virus dan echovirus)
31. b. komplikasi dari myocarditis adalah : - fatal heart failure dan arrythmia
- myocardial dysfunction
32. C
33.?
34. D. etio dari subacute endocarditis yang saya dapat adalah bakteri gram negative HACEK dan S.viridans.. tapi S.viridans memiliki angka kejadian 50-60% dari subacute endocarditis
39. B. polyarthritis : >=75%; carditis = 40-60%; chorea = 5-36%; erythema marginatum lalu subcutaneous nodule prevelansi hanya angka satuan persen.
40. C. based on major dan minor criteria, paling sering untuk muncul dan memperkuat diagnosis RF adalah major. Maka itu salicylate untuk relieve dari arthritis. Fever dapar diminish tanpa antipyretic therapy dalam 1 minggu atau low grade fever persisten selama 2 minggu.
61. D
62. C
63. A
64. D
65. B (ga yakin,sori)
66. A
67. C
68. ga ada soalnya
69. C
70. D
71. D
72. ga tau,sori
73. C
74. D
75. A
76. A
77. ga tau,sori
78. D
79. D
80. D

161. Of the following statement regarding the ECG of a patient with history of coronary artery disease below is true, except
A. sinus rhythm with 1st degree AV block
B. myocardial infarction, age undetermined
C. pair of PVCs
D. ventricular tachycardia
Jawab: A
Pembahasan:
Dari gambar EKG, terlihat jelas bahwa pasien mengalami tachyarrhythmia (jarak kompleks R ke R berikutnya sempit).
Karena QRS kompleks-nya lebar, maka bisa kita simpulkan bahwa ini adalah ventricular tachyarrhythmia.
Lihat di bagian tengah hingga akhir gambaran EKG, bentuk gelombangnya monomorphic. Maka bisa disimpulkan ini adalah monomorphic ventricular tachycardia. Monomorphic VT biasa terjadi karena adanya abnormalitas struktural yang mendukung terbentuknya suatu reentry circuit, biasanya karena ada myocardial scar karena old infarct atau cardiomyopathy. Secara definisi, VT adalah “a series of three or more VPB/PVCs”.
Jadi option B, C, D benar.
Option A salah karena 1st degree AV block termanifestasi sebagai bradyarrhythmia dengan pemanjangan PR interval.

162. From the features of ECG of a patient in his 5th day in the CCU below, which statement is not?
A. normal sinus rhythm
B. recent myocardial infarction
C. a possible left ventricular aneurysm
D. PACs with trigeminy pattern
E. non-compensatory pause
Jawab: B
Pembahasan:
Dari gambar, terlihat:
1. Ada PAB/PAC (gelombang EKG yang kedua ke yang pertama jaraknya lebih sempit daripada jarak gelombang EKG yang kedua ke yang ketiga).
2. Ada elevasi ST segmen
Maka,
Opsi A salah, ada PAC  bukan sinus rhythm.
Opsi B benar, ada elevasi segmen ST  new/recent myocardial infarction
Opsi C salah, LV aneurysm biasanya ditunjukkan dengan gambaran sustained VT.
Opsi D tidak bisa dinilai, karena trigeminy berarti ada satu PAC dalam setiap 3 beat. Gambar tidak cukup panjang untuk menilai ini.
Opsi E salah, tidak terlihat pause.

163. All the statement below regarding the features of ECG of a 52-year-old male patient with chest pain and hypoventilation are true, except
A. sinus rhythm with 3rd degree AV block
B. 2nd degree AV block type 1
C. functional escape rhythm
D. acute inferior wall myocardial infarction
E. reciprocal ST-T changes at 1, aVL, V1-V4
Jawab: ?? Tidak ada gambaran EKG-nya!
Pembahasan opsi:
Opsi A: sinus rhythm with 3rd degree AV block  secara definisi salah. 3rd degree AV block terjadi jika ada “complete failure of conduction between the atria and ventricles”, berarti depolarisasi atrium (gelombang P) dan depolarisasi ventrikel (kompleks QRS) akan berjalan sendiri-sendiri. Sementara, salah satu syarat sinus rhythm adalah gelombang P yang selalu diikuti kompleks QRS.
Opsi B: 2nd degree AV block type 1  ciri-cirinya ada prolongation dari interval PR dari beat ke beat hingga pada satu titik, impulse dari atrium tidak dikonduksikan ke ventrikel (gelombang P tanpa kompleks QRS), lalu siklus berulang.
Opsi C: functional escape rhythm  ada gambaran PAC (PAB) atau PVB (PVC).
Opsi D: acute inferior wall MI  mungkin saja benar, karena pasien sedang mengalami chest pain.
Opsi E: reciprocal ST-T changes pada lead I, aVL (lateral) dan V1-V4 (anterior)  berarti MI-nya terjadi pada dinding inferior? Sama dengan opsi D.

164. Which of the following statement regarding ventricular arrhythmia in the ECG below is true
A. VCs multifocal, with R-on-T phenomenon, atrial fibrillation
B. VCs multifocal, with R-on-T phenomenon, paired PVC, atrial fibrillation
C. VCs multifocal, with R-on-T phenomenon, paired PVC
D. VCs multifocal, with R-on-T phenomenon, non-sustained ventricular tachycardia
E. VCs multifocal, with R-on-T phenomenon, paired PVC, non-sustained ventricular tachycardia
Jawab: jawaban 2006: C

165. Which of the following statement regarding the features in the ECG below is true?
A. atrial flutter with ventricular facing bea
B. atrial flutter with consecutive PVCs
C. atrial fibrillation
Jawab: C (sepertinya, karena P wave-nya tidak jelas)

166. Which of the following statement regarding atrioventricular block is not true?
A. 2nd degree AV block type I is usually located at the AV nodal level
B. 2nd degree AV block type II is usually located at the intranodal level
C. asymptomatic patients with a 3rd degree AV block at the AV nodal level should have permanent pacing
D. the slight variation in the patients in sinus rhythm and 3rd degree AV block
E. pacing is not indicated in patients with 1st degree AV block
Jawab: C
Pembahasan:
Atrioventricular Block
1. First Degree AV Block
• The impairment of conduction is usually within the AV node itself.
• During first-degree AV block, every atrial impulse conducts to the ventricles and a regular ventricular rate is produced, but the PR interval exceeds 0.20 second in adults.
• Clinically important PR interval prolongation can result from a conduction delay in the AV node (A-H interval), in the His-Purkinje system (H-V interval), or at both sites.
2. Second Degree AV Block
• Mobitz Type I block is usually as a result of intermittent impairment in AV node itself, while Type II block is usually due to that in His-Purkinje system.
• Blocking of some atrial impulses conducted to the ventricle at a time when physiological interference is not involved constitutes second-degree AV block.
• The nonconducted P wave can be intermittent or frequent, at regular or irregular intervals, and can be preceded by fixed or lengthening PR intervals.
• Electrocardiographically, typical type I second-degree AV block is characterized by progressive PR prolongation culminating in a nonconducted P wave , whereas in type II second-degree AV block, the PR interval remains constant prior to the blocked P wave
3. 3rd Degree AV Block
• Third degree or complete AV block occurs when no atrial activity is conducted to the ventricles and therefore the atria and ventricles are controlled by independent pacemakers  complete AV dissociation.
• The atrial pacemaker can be sinus or ectopic (tachycardia, flutter, or fibrillation) or can result from an AV junctional focus occurring above the block with retrograde atrial conduction. The ventricular focus is usually located just below the region of the block, which can be above or below the His bundle bifurcation.
• Complete AV block can result from block at the level of the AV node (usually congenital), within the bundle of His, or distal to it in the Purkinje system (usually acquired).

Management AV block:
• Drugs cannot be relied on to increase the heart rate for more than several hours to several days in patients with symptomatic heart block without producing significant side effects
• temporary or permanent pacemaker insertion is indicated for patients with symptomatic bradyarrhythmias
• For short-term therapy, when the block is likely to be evanescent but still requires treatment or until adequate pacing therapy can be established, vagolytic agents such as atropine are useful for patients who have AV nodal disturbances, whereas catecholamines such as isoproterenol can be used transiently to treat patients who have heart block at any site.
• For symptomatic AV block or high-grade AV block (e.g., infrahisian, type II AV block, third-degree heart block not caused by congenital AV block), permanent pacemaker placement is the treatment of choice

Dari pembahasan di atas, maka
Opsi A benar.
Opsi B benar.
Opsi C salah (3rd degree AV block pada AV nodal level biasanya congenital, jadi tidak perlu pacemaker, apalagi jika asymptomatic).
Opsi D ??
Opsi E benar.

167. Which of the following statements regarding electrical abnormalities in the heart and sudden cardiac death is true?
A. arrhythmic events in patients with long QT syndromes I are often triggered by auditory stimuli
B. the risk of sudden death in Wolff-Parkinson-White Syndrome is high and often occurs in otherwise healthy individuals
C. patients with idiopathic polymorphic ventricular tachycardia have a good prognosis
D. younger patients who survived SCD have a higher incidence of idiopathic ventricular fibrillation
E. most cases of idiopathic ventricular tachycardia originate from the left ventricular outflow tract
Jawab: paling mungkin sih B
Pembahasan:
Opsi A: Long QT syndrome I  Di Braunwald disebutkan, pada LQTS, “Patients should undergo prolonged electrocardiographic recording with various stresses designed to evoke ventricular arrhythmias, such as auditory stimuli, psychological stress, cold pressor stimulation, and exercise.”  arrhythmic events bisa ditrigger oleh auditory stimuli.
Opsi B: Wolf-Parkinson-White Syndrome  the anomalous pathways of conduction, bundles of Kent in the Wolff-Parkinson-White syndrome and Mahaim fibers, are commonly associated with nonlethal arrhythmias. However, when the anomalous pathways of conduction have short refractory periods, the occurrence of atrial fibrillation may allow the initiation of VF during very rapid conduction across the bypass tract .
Opsi C dan E: idiopathic polymorphic VT  polymorphic VT (seperti torsades de pointes) biasanya akan berdegenerasi menjadi VF yang sering menjadi penyebab sudden cardiac death. Jadi, prognosisnya buruk. Opsi E juga kemungkinan salah karena VT tidak mungkin berasal dari outflow tract LV (dekat aorta).
Opsi D: sudden cardiac death.. g nemu.

168. As anti-arrhythmic agent, the mechanism of action of amiodarone is
A. blocking Na channel
B. blocking Ca channel
C. blocking K channel
D. sympatholytic action
E. inhibiting Na-K ATP-ase
Jawab: A
Pembahasan:
AMIODARONE
Effects:
• Acute effects include prolong action potential duration of ventricular muscle but shorten the action potential duration of Purkinje fibers. They also reduce sinus and junctional discharge rates and prolong AV nodal conduction time.
• Chronically, amiodarone prolongs action potential duration and refractoriness of all cardiac fibers without affecting resting membrane potential.
• Hemodynamically, amiodarone is a peripheral and coronary vasodilator. It decreases heart rate, systemic vascular resistance, LV contractile force. However, because it is able to control the arrhythmia, it does not reduce ejection fraction nor cardiac output.
Mechanism of action:
1. It blocks the inactivated sodium channel, therefore reducing maximum conduction velocity.
2. It increases resistance to passive current flow.
3. It antagonizes alpha and beta receptor noncompetitively
4. It blocks conversion of thyroxine (T4) to triiodothyronine (T3)
Sumber: Braunwald

169. Which of the following is the best therapy to relieve symptom in acute pericarditis?
A. oral antisteroidal anti-inflammatory agents and colchicines
B. oral antisteroidal anti-inflammatory agents and indomethacine
C. oral antistreoidal anti-inflammatory agents and corticosteroid
D. corticosteroid: colchicines and indomethacine
E. corticosteroid
Jawab: A
Pembahasan:
Management Acute Pericarditis
Management dari pericarditis bertujuan:
- Deteksi etiologi yang memiliki implikasi terhadap management (misal, jadi harus ganti antibiotic)
- Deteksi effusion dan other echocardiographic abnormalities
- Meringankan symptom
- Treatment yang sesuai dengan etiologi yang spesifik
Acute idiopathic pericarditis merupakan self-limited disease tanpa komplikasi yang significan dan tanpa reccurence pada 70-90% pasien. Jika lab menunjukkan idiopathic acute pericarditis, maka NSAID (biasanya ibuprofen 600-800 mg p.o. tdd) hingga 2 minggu jika nyeri dada sudah tidak dirasakan lagi.
Jika pasien tidak merespon dengan baik pada awal pemberian NSAID, maka sebaiknya diopname untuk observasi dan tes tambahan.
Jika pasien merespon secara lambat, maka diperlukan tambahan analgesic narcotic dan/atau colchicines atau prednisone.
Pada pasien yang mengalami RECURRENT acute idiopathic pericarditis (15-30% dari pasien yang merespon secara memuaskan thd management yang disebutkan di atas), perlu dilakukan evaluasi untuk kemungkinan penyakit autoimmune, dan kadang (jarang) diperlukan biopsi pericardium. Pada kelompok pasien ini, diberikan lagi NSAID selama 2 minggu, lalu diberikan colchicines prophylaxis. Jika pasien tidak membaik, maka diberikan short course of prednisone ketika terasa gejala, namun ini tidak dilakukan secara kronis. Pericardiotomy bisa juga dilakukan, tapi hanya efektif pada sebagian kecil pasien.
Sumber: Braunwald

170. A 30-year-old man came to ER with fever and chest pain. On physical examination, pericardial friction rub was heard. Laboratory finding revealed elevated WBC and ESR. Which of the following is a typical presentation of acute pericarditis?
A. the onset of pain is usually crescendo
B. the patient feels more comfortable in recumbence
C. abnormal S3 and S4
D. pulmonary congestion may be present in severe pericarditis
E. rub can last hours to days
Jawab: A
Pembahasan:
ACUTE PERICARDITIS
Sign and symptom:
6. Chest pain (pasien hampir selalu datang dengan keluhan ini), nyerinya severe. Kualitasnya rapid onset, terletak substernal (bisa juga pada dada kiri atau epigastrium kiri), dan biasa beradiasi ke lengan kiri atau ke trapezius ridge. Nyeri akan membaik jika duduk membungkuk dan akan memburuk jika berbaring.
7. Dyspnea
8. Fever
9. Cough
10. Hiccoughs (hiccups)
Pemeriksaan Fisik:
4. Pasien terlihat uncomfortable, anxious
5. Vital signs: low-grade fever, sinus tachycardia
6. Auskultasi jantung: ada friction rub yang terdiri atas 3 komponen. Komponen pertama terjadi pada ventricular systole, lalu pada early diastolic filling, dan pada atrial contraction. Bunyinya mirip suara berjalan pada crunchy snow. Rub paling terdengar pada lower left sternal border hingga cardiac apex, dan paling keras jika posisi pasien duduk membungkuk. Rub-nya dinamis, kadang muncul kadang menghilang.
Sumber: Braunwald
Dari Lilly disebutkan, onset dari chest pain biasanya crescendo.
Opsi A benar
Opsi B salah, pasien memburuk jika berbaring
Opsi C salah, tidak ada S3 dan S4
Opsi D salah, tidak ada pulmonary congestion
Opsi E salah, karena rub intermittent.

171. Which of the following ECG changes are typical for acute pericarditis?
A. inverted T waves while ST segment still elevated
B. localized convex ST segment elevation
C. diffuse concave ST segment elevation
D. frequent PVCs
E. first degree AV block
Jawab: C
Pembahasan:
Electrocardiogram pada acute pericarditis menunjukkan temuan-temuan sbb:
4. Diffuse ST segment elevation (merupakan classic finding dalam perikarditis akut).
5. Depresi segmen PR  merupakan manifestasi yang lebih awal, biasanya terjadi sebelum ada rub maupun elevasi segmen ST
6. Sangat jarang terjadi elevasi ST yang berprogresi ke depresi segmen ST disertai inversi gelombang T.
Sumber: Braunwald

172. Which of the following statement is true?
A. Acute pericarditis produces dull retrosternal pain
B. Pericardial friction rub is the hallmark of acute pericarditis
C. The stethoscope bell should be placed firmly on the chest wall
D. Most pericardial friction rubs are louder during expiration
E. ASA 650 mg, q3-4th is the drug of choice in recurrent pericarditis
Jawab: B
Pembahasan:
Lihat pembahasan no. 169-170
Opsi A salah, pada acute pericarditis, nyeri dada berkualitas sharp
Opsi C salah, tidak disebutkan bahwa pericardial rub hanya terdengar jika menggunakan bell.
Opsi D salah, pericardial friction rub bisa ada dan menghilang secara tiba-tiba (intermittent).
Opsi E tidak sepenuhnya benar, pada recurrent pericarditis, harus diberikan prophylaxis berupa colchicines juga.
Opsi B benar, karena friction rub paling parah terdengar saat fase pericarditis. Saat fase effusion, friction rub makin melemah. Karena itu, friction rub adalah hallmark dari pericarditis.

173. Which of the following regarding the physical examination of cardiac tamponade is true?
A. Elevation of pericardial pressure, pulsus paradoxus, and arterial hypertension
B. Basal rales are typically present
C. There is rapid x descent, pulsus paradoxus, and arterial hypotension
D. There are rapid x and y descent in the jugular venous pulse
E. There are normal jugular venous pressure and pulsus alternans
Jawab: C
Pembahasan:
Patofisiologi Cardiac Tamponade (CT)
CT dicirikan dengan suatu continuum yang dimulai dari efusi pericardium tanpa efek yang jelas yang berlanjut ke circulatory collapse. Ini tergantung pada tekanan di pericardium (yg meningkat karena efusi) dan kemampuan jantung untuk mengkompensasi peningkatan tekanan tersebut.
Volume cairan di pericardium biasanya hanya sedikit, jadi peningkatan jumlah cairan yang rapid, walaupun dalam jumlah kecil, dapat dengan cepat meningkatkan tekanan pericardium dan berpengaruh pada fungsi jantung. Sebaliknya, slowly accumulating effusion, walaupun jumlahnya besar, dapat ditolerir dengan baik.
Kompensasi jantung bergantung terutama pada respon sympathetic untuk meningkatkan heart rate dan kontraktilitas. Pada pasien yang meminum beta-blocker, maka respon ini minimal dan kompensasi jantung tidak maksimal.
Seiring dengan menumpuknya cairan pada pericardial cavity, akan terjadi peningkatan tekanan diastolic pada ruang-ruang jantung sehingga tekanannya sama dengan tekanan pad pericardial cavity (fenomena ini disebut equalization). Karena meningkatnya tekanan, maka volume darah di jantung akan berkurang (preload berkurang), menyebabkan berkurangnya stroke volume. Karena jantung kanan dindingnya lebih tipis dan kurang bisa beradaptasi terhadap peningkatan tekanan, maka peningkatan tekanan di jantung kanan lebih cepat daripada di jantung kiri (namun pada akhirnya akan mencapai tekanan yg sama, yakni tekanan pericardial cavity).
Kelainan hemodinamik lainnya:
3. Loss of y descent of RA (or systemic venous) pressure (without loss of x descent)
Ini didasarkan pada konsep bahwa, pada severe CT, total heart volume tetap (tidak berkurang maupun bertambah, tidak dipengaruhi oleh kontraksi-relaksasi). Karena itu, darah hanya bisa mengalir ke jantung saat darah (yang tadinya ada di jantung) dipompa keluar. Karena itu, y descent, yang menggambarkan penurunan tekanan atrium setelah atrium berkontraksi, tidak tergambarkan.
4. Paradoxical pulse
Paradoxical pulse menggambarkan berkurangnya tekanan arteri sistemik secara abnormal (>10 mmHg) saat inspirasi. Pada CT (dan secara fisiologis), terjadi peningkatan systemic venous return saat inspirasi (sehingga systemic venous pressure berkurang). Ketika total volume jantung tetap, maka peningkatan venous return ini akan menyebabkan interventricular septum untuk shift to the left saat inspirasi, sehingga membuat LV menjadi sempit, dan stroke volume (LV pressure) berkurang secara abnormal. Karena itu, tekanan arteri sistemik pun berkurang saat inspirasi.
Diagnosis Cardiac Tamponade
f. Anamnesis: pasien mengeluhkan dyspnea, kadang ada pericardial pain atau discomfort, yang akan membaik jika duduk membungkuk (sitting and leaning forward). Terdapat pula gejala-gejala yang berkaitan dengan berkurangnya cardiac output, seperti fatigue, weakness, dizziness.
g. Physical examination: Beck’s triad (hypotension, muffled heart sounds, elevated jugular venous pressure), tachypnea, diaphoresis, cool extremities, peripheral cyanosis, depressed sensorium, yawning. Terdapat pulsus paradoxus. Cardiac impulse tidak ada atau berkurang. Terdapat friction rub.
h. Radiography: = pericardial effusion
i. Electrocardiography: = pericardial effusion
j. Echocardiography: lucent separation between parietal and visceral pericardium is circumferential (usually). Ada collapse dari RV pada saat early diastole dan collapse pada RA pada saat ventricular diastole (kalau tidak ada collapse, biasanya menunjukkan effusion, bukan tamponade).

174. Which of the following statement is NOT true about pathophysiology of cardiac tamponade?
A. Cardiac tamponade occurs when intracardial pressure is equal to RA and RV diastolic pressure
B. In the presence of hypovolemia, cardiac tamponade may be more difficult to detect
C. Equalization of intrapericardial and ventricular filling pressure may lead initially to a small increase in stroke volume
D. Sinus bradycardia may occur during severe cardiac tamponade
E. Hemodynamic deterioration during tamponade is dependent upon atria; compression during diastole
Jawab: C
Pembahasan:
Lihat patofisiologi cardiac tamponade (CT) di no. 173

175. Which of the following statement about bacterial pericarditis is NOT true?
A. Uremic pericarditis may predispose to the development of purulent bacterial pericarditis
B. Direct extension into pericardium of bacterial pneumonia accounts for the majority of cases of purulent pericarditis
C. Bacterial pericarditis is most often an acute fulminant illness that develops over a few days
D. Long term survival after purulent bacterial pericarditis remains poor despite the availability of antibacterial therapy
E. High concentration of antibiotics may be achieved in pericardial fluid
Jawab: A
Pembahasan:
BACTERIAL PERICARDITIS
1. Etiologi
Bacterial pericarditis is usually characterized by a purulent effusion. Direct extension from pneumonia or empyema accounts for a majority of cases. The most common agents are staphylococci, pneumococci, and streptococci. Hematogenous spread during bacteremia and contiguous spread after thoracic surgery or trauma are also important mechanisms. Hospital-acquired, penicillin-resistant staphylococcal pericarditis following thoracic surgery has been increasing. Anaerobic organisms are also increasing in frequency. Concomitant infection in the mediastinum, head, or neck is commonly associated with anaerobes.
2. Clinical Features
The clinical presentation of bacterial pericarditis is usually high-grade fever with shaking chills and tachycardia, but these may be absent in debilitated patients. Patients may complain of dyspnea and chest pain. A pericardial friction rub is present in the majority. Bacterial pericarditis can take a fulminant course with rapid development of tamponade and may be unsuspected because associated illnesses such as severe pneumonia or mediastinitis following thoracic surgery dominate the clinical picture.
3. Management
Suspected or proven bacterial pericarditis should be considered a medical emergency, and prompt closed pericardiocentesis or surgical drainage performed. We recommend at least 3 to 4 days of subsequent catheter drainage. The actual length is dependent on the volume and nature (i.e., purulence) of the fluid. Fluid should be Gram stained and cultured for aerobic and anaerobic bacteria with appropriate antibiotic sensitivity testing. Fungal and tuberculosis staining and cultures should also be performed. Blood, sputum, urine, and recent surgical wounds should all be cultured. Broad-spectrum antibiotics should be started promptly and then modified according to culture results. Anaerobic coverage is critical when pericarditis associated with head and neck infections is suspected.
4. Prognosis
The prognosis of bacterial pericarditis is generally poor, with survival in the range of 30 percent even in modern series

KLASIFIKASI PERICARDITIS (menurut Lilly)
A. Infectious
1. Idiopathic and viral pericarditis
2. Tuberculous pericarditis
3. Nontuberculous bacterial pericarditis (purulent pericarditis)
B. Non-Infectious
1. Pericarditis following myocardial infarction
2. Uremic pericarditis
3. Neoplastic pericarditis
4. Radiation-induced pericarditis
5. Pericarditis associated with connective tissue diseases
6. Drug-induced pericarditis

Opsi A salah, karena uremic pericarditis adalah salah satu jenis pericarditis noninfectious.
Opsi B benar (lihat pembahasan)
Opsi C benar (lihat pembahasan)
Opsi D benar (lihat pembahasan)
Opsi E g nemu, tapi sepertinya benar.

176. Streptococcus sp. Cause endocarditis in about 70% of cases. Streptococcus viridans are the most common pathogens, followed by enterococci. The procedure to detect this organism is obtaining blood for?
A. Bacterial culture
B. Microscopic observed
C. Specific IgG detection
D. Immune detection
E. Hemolytic test
Jawab: A
Pada endocarditis, criteria yang dipakai adalah Duke’s criteria, dimana salah satu major criterianya adalah positive blood culture. Hanya Coxiella burnetti yang boleh didemonstrasikan melalui IgG titer.
Major criteria:
Positive blood culture
Typical microorganism for infective endocarditis from two separate blood cultures
Viridans streptococci, Streptococcus bovis, HACEK group or
Staphylococcus aureus or community-acquired enterococci in the absence of a primary focus, or
Persistently positive blood culture, defined as recovery of a microorganism consistent with infective endocarditis from:
Blood cultures (≥2) drawn more than 12 hr apart, or
All of three or a majority of four or more separate blood cultures, with first and last drawn at least 1 hr apart
Single positive blood culture for Coxiella burnetii or antiphase I IgG antibody titer >1:800

177. Which method is correct to detect a streptococcus in rheumatic fever?
A. Bacterial culture and identification
B. Antistreptolysin O Test
C. Bacteracin test
D. Lancefield test
E. M. protein test
Jawab: B
Pembahasan: cukup jelas :-)

179. Group A streptococcus, which causes rheumatic fever characterized by one of the following mechanism?
A. it produces an erythrogenic toxin
B. it causes beta hemolysis
C. its pathogenicity is by the M protein
D. it causes anti streptolysion O production
E. it produces a hemolysin that dissolves red blood cells
Jawab: C
Pembahasan:
Opsi B, C, D, E benar, tetapi yang berkaitan dengan mekanisme yang menyebabkan rheumatic fever adalah M protein yang secara struktural banyak memiliki kemiripan dengan protein-protein di tubuh.


180. Transient bacteremia is common after minor surgical procedures and bacteria can colonize and multiply in cardiac endothelium. The organism causing endocarditis is all of the following, except …
A. Streptococcus viridans
B. Staphylococcus aureus
C. Staphylococcus epidermidis
D. Escherichia coli
E. Clostridium tetani
Jawab: B
Pembahasan: cukup jelas ya..

MDE CVS 2006

1. Jawaban : C. Long absolute rafractory period
Alasan : guyton hlm 105
2. Jawaban : AV sulcus
Alasan : Moore hlm 158 tabel
3. Jawaban : E. Mital valve
Alasan : komponen S1 terdiri atas mitral dan tricuspid dengan mitral mendahului triscuspid (Lilly hlm 32)
4. Jawaban : D. Chordae tendinae
Alasan : Chordae tendinae menhubungkan papillary muscles dengan cusp dari valve
5. Jawaban :
Alasan :
6. Jawaban : ???
Alasan : Lilly hlm 320  angiotensin 1 diubah membtutuhkan renin,jadi klo renin ↑  ↑ angiotensin 1. Di hlm 319  estrogen ↑ angiotensinogen, jadi klo ada opsinya pilih renin,klo ga ada mungkin estrogen
7. Jawaban : E. Elevation of arterial presure
Alasan : harusnya decrease of arterial pressure
8. Jawaban : C. Cardiac ventricles
Alasan : slide minilecture biokimia
9. Jawaban : D. Local hormone
Alasan : slide minilecture biokimia
10. Jawaban : C. Angiotensinase
Alasan : angiotensinase berfungsi untuk mendegradasi angiotensin II  sebenernya ga yakin juga da pengaruhnya ada apa ga,tapi enzim ini jarang disebut...^_^
11. Jawaban : B. Ailmentary system
Alasan : Lilly hlm 312
12. Jawaban : C. C-type natriuretic peptide
Alasan : ga ditemukan di sirkulasi (slide minilecture biokimia)
13. Jawaban : B. Endothelin
Alasan : slide minilecture biokimia
14. Jawaban : D. Decreased perfusion pressure
Alasan : Jurnal tentang cardiac remodelling
15. Jawaban : E. Hypertrophy of cardiac cells
Alasan : Jurnal tentang cardiac remodelling
16. Jawaban : D. Calcium binding protein
Alasan : Jurnal tentang cardiac remodelling
17. Jawaban : B. CKMB
Alasan : cardiac enzyme utama adalah CKMB dan troponin
18. Jawaban : ???
Alasan : di Moore yang disebut-sebut tentang heart tube,tapi kalau mentok2 mungkin yang A
19. Jawaban : ???
Alasan : soalnya kurang lengkap, tapikayaknya sih E soalnya jantung berasal dari splanchnic mesoderm
20. Jawaban : E
Alasan : karena berasal dari existing layer, kalau dari blood island namanya vasculogenesis
21. c. lange embriologi, di atas subbab pembentukan rongga jantung
22. b. note: arch V tidak pernah terbentuk
23. B.
-3rd aortic arch  carotid communis
- 4th kiri  part of arch aorta
- 4th kanan  prox subclavia kanan
- 5th  ga kebentuk
- 6th  lengkung pulmonal  kiri-kanan membentuk arch pulmonal
24. b. lange embriologi di subbab perubahan-perubahan saat lahir
25. e
26. B
27. a. di braunwald hal 157, PR interval terdapat delayed (di AV node) dari atrial depolarization dan ventricle depolarization dengan gambaran isoelectric (reduced amplitude)
28. C. karena punya hiperpolarisasi voltage akhir lebih positif dibandingkan dengan berkas listrik jantung yang lain sehingga automatisasinya paling cepat.
29. d
30. e.
31. CO = (EDV-ESV) x HR note = EDV-ESV adalah stroke volume
96 = (EDV-ESV) x 70
137mL = EDV-ESV
137 + 106 = EDV
243 ml = EDV
32. MAP = 1/3 systole + 2/3 diastole
100 = 1/3 S + 2/3. 90
40 = 1/3 S
120 = systole
Pulse pressure = Systole – Diastole
120- 90
30 mmHg
33. nilai normal: MAP = 70-105 mmHg; 2-6 mmHg; RVP systole: 15-25 mmHg; RVP diastole: 0-8 mmHg, LAP: 6-12 mmHg
RAP = right atrial pressure ; RVP: Right Ventricular pressure; MAP: mean arterial pressure
34. c. masukin rumus no 31
35.C. autonomic neural di jantung (termasuk vagal nerve) punya pola iinnervasi “sidedness”. Right Vagus nerves affecting sinus node dibandingkan AV node (slows sinus node discharde), sedangkan Left autonomic nerves affecting AV node more than sinus node (prolonges AV nodal conduction time and refractoriness).. tapi statement berikutnya: negative dromotropic response of the heart to vagal stimulation result hyperpolarization of the AV nodal cells.
36. D
37. D. kalo sound ke 2 dari penutupan semilunar valve
38. s4 terjadi karena ventricular compliance yang jelek sehingga terjadi atrial contraction yg menimbulkan s4 tersebut dan terdengar pada akhir atrial filling phase of ventricular diastole
39. e.
40. d. Within physiologic range, the larger ventricular volume during diastole, the more the fibers are stretched before stimulation, the greater the force of the next contraction
61. D
62. B
63. ga tau,sori
64. C
65. B
66. D
67. C
68. A
69. C
70. B
71. E
72. A (iv,im,parenteral,rectal,ophthalmic,topical,epidural,intraspinal,injection) dan B (ventricular a.)
73. D dan E
74. D
75. A
76. C (adenosine is an endogenous nucleoside.administered IV, it is the most effective drug for the rapid termination of reentrant PSVT-lily 430)
77. A
78. C
79. B
80. D

163. The key indication for considering a diagnosis of the COPD are the following EXCEPT:
A. chronic cough present intermittently
B. chronic sputum production
C. progressive dyspnea on exertion
D. left heart failure
E. history of exposure cooking smoke
Jawab: D dan E.
Pembahasan:
Key Indicators for Considering a Diagnosis of Chronic Obstructive Pulmonary Disease (COPD):
1. Chronic cough that is present intermittently or everyday or that is often present throughout the day. Merely nocturnal cough is seldom.
2. Chronic sputum production, any pattern
3. Dyspnea that is progressive, persistent, described as “increased effort to breathe”, “heaviness”, “air hunger”, “gasping”, worsen on exercise, and worsen during respiration
4. History of exposure to risk factors, such as tobacco smoke, occupational dusts, and chemicals.
A, B, C adalah key indication untuk diagnosis (point 1, 2, 3)
D benar karena COPD berkaitan dengan right heart failure, bukan left.
E benar karena cooking smoke bukan termasuk faktor risiko COPD.

164. The following are the definitions of COPD, except
A. cystic fibrosis and asthma
B. smoking is the major risk factor
C. irreversible air flow obstruction
D. bronchitis and emphysema
E. limited reversible air flow obstruction by bronchodilator
Jawab: A
Menurut expert panel dari American Thoracic Society, European Thoracic Society, British Thoracic Society, dan Global Initiative for Chronic Obstructive Lung Disease (GOLD), keypoint dalam definisi COPD adalah sbb:
1. Irreversible airflow obstruction
2. Although limited reversibility of airflow obstruction in response to bronchodilators is common, it does not preclude bronchodilator treatment.
3. Neither asthma with complete reversibility nor chronic airflow obstruction caused by diagnosable conditions such as cystic fibrosis, obliterative bronchiolitis, or panbronchiolitis is included in the definition of COPD.
4. Tobacco smoking is the major, but not only, risk factor for COPD.
5. The cause of irreversible airflow obstruction in patients with COPD is the presence in the lungs of bronchiolitis or small airway disease and emphysema, which are present to a variable mix among patients.
Dari point no. 3, jelas, cystic fibrosis dan asthma bukan definisi COPD.

165. Oxygen therapy improves survival in COPD by following, except
A. it corrects pulmonary vasoconstriction
B. it increases right ventricular stroke volume
C. it improves oxygen delivery to the heart
D. it prevents tachyarrythmia
E. it corrects hypoxemia
Jawab: D
Pembahasan:
Dengan low-flow supplemental oxygen, maka hypoxemia pada COPD akan dengan mudah dikoreksi.
Pada patofisiologi COPD, diketahui bahwa hypoxemia dapat menyebabkan remodeling dari arteri pulmonalis, yang akan menyebabkan vasokonsitriksi. Vasokonstriksi arteri pulmonalis menyebabkan pulmonary hypertension, sehingga meningkatkan afterload dari RV, menyebabkan berkurangnya stroke volume RV.
Hypoxemia, secara definisi, adalah konsentrasi oksigen yang kurang dari normal pada darah. Ketika ini dikoreksi dengan oksigen, maka konsentrasi oksigen meningkat, termasuk konsentrasi oksigen pada darah yang mengalir ke jantung.
Jadi, opsi A, B, C, E memang merupakan efek dari oxygen therapy.

166. The physical signs of pulmonary hypertension includes all of the following, except
A. signs of pulmonary edema
B. left parasternal heave
C. systolic pulsation in 2nd …
D. ejection click and …
E. closely-split S2, loud pulmonary sound
Jawab: A
Pembahasan:
Diagnsosis pulmonary hypertension adalah sbb:
1. History Taking
Pasien biasa datang dengan keluhan dyspnea on effort.
Jika RV failure telah terjadi, akan didapatkan edema pada tungkai bawah.
Pada penyakit yang parah, pasien bisa mengalami angina karena RV mengalami hipertrofi yang prominen sehingga mengurangi aliran darah pada coronary artery.
Cardiac output yang berkurang dapat menyebabkan gejala seperti syncope atau near syncope.
Pasien juga mengalami gejala LV diastolic dysfunction seperti orthopnea, paroxysmal nocturnal dyspnea.
Jika pasien memiliki penyakit paru-paru, maka akan didapati coughing.
Hemoptysis bisa didapati jika pasien mengalami hypertension pulmonal karena thromboembolism atau mitral stenosis.
2. Physical Examination
a. Gelombang a yang besar pada jugular venous pulse
b. Peningkatan JVP
c. Left parasternal (RV) heave
d. Systolic pulsation pada ICS 2 karena arteri pulmonalis yang tegang mengalami dilatasi
e. a closely split second heart sound with a loud pulmonic component
f. Ejection click, flow murmur pada ICS 2
g. S4 di daerah RV
h. Tanda-tanda RV (hepatomegaly, peripheral edema, ascites)
i. Cyanosis (jika cardiac output sangat berkurang dan ada vasokonstriksi sistemik)
j. Ortner syndrome (paralysis left recurrent laryngeal nerve karena kompresi dari pulmonary artery)
Sumber: Braunwald

167. Which of the following statement regarding pulmonary hypertension is TRUE
A. The ECG is the most reliable tool in diagnosing obstructed artery disease
B. The gold standard method for diagnosing pulmonary hypertension is echocardiogram
C. the degree of pulmonary hypertension is usually less severe in chronic lung disease
D. autonomic innervations of the vascular …
E. pulmonary congestion and edema are the hallmark of pulmonary hypertension
Jawab: C
Pembahasan:
Kita lihat per option…
Opsi A, tentang ECG:
“The detection of right ventricular hypertrophy on the electrocardiogram is highly specific but has a low sensitivity. It usually exhibits RA & RV enlargement, T wave inversion in anterior precordial leads. These are less pronounced in COPD patients because of the modest degree of pulmonary hypertension and because of the effects of hyperinflation.”
Low sensitivity, high specificity  jadi kurang reliable dalam mendiagnosis obstruksi untuk pulmonary hypertension.
Opsi B, tentang echocardiogram:
“Echocardiography demonstrates enlargement of RA and RV, normal or small LV, and thickened IV septum. There is abnormal septal motion due to RV pressure overload. Detection of RVH is limited by ability of echocardiograph to differentiate RV wall from surrounding structure. RV dysfunction is also difficult to quantitate echocardiographically.”
Jadi jelas echocardiogram bukan gold standard.
Di paragraph ini yang tentang ECG (opsi A), disebutkan juga bahwa pada pasien COPD, pulmonary hypertension-nya modest (tidak parah), berarti opsi C benar.
Opsi D kurang lengkap.
Opsi E salah, karena pada pulmonary hypertension, yang menjadi concern adalah RV failure yang menyebabkan congesti vena sistemik dan edema pada liver atau pedis. Sementara, pulmonary congestion dan edema adalah karakteristik dari LV failure.

168. During normal pregnancy, systemic vascular resistance falls due to the following
A. increased heat production
B. incrased innervations
C. increased prostaglandin synthesis
D. low … circulation
Jawab: C
Pembahasan:
Perubahan hemodinamik pada kehamilan:
1. Berkurangnya resistensi vaskular sistemik maupun vaskular pulmonal. Ini disebabkan beberapa hal:
a. Cardiac natriuretic peptide
ANP dan BNP diproduksi oleh cardiomyocyte, dan akan meningkatkan natriuresis dan diuresis. Selain itu, ANP dan BNP akan meningkatkan relaksasi otot polos vaskular.
b. Prostaglandin
PGI2 (prostacyclin) banyak disintesis di akhir kehamilan. Ini akan meningkatkan resistensi endothel terhadap angiotensin, sehingga meskipun kadar angiotensin meningkat, endothel tidak responsive terhadap angiotensin.
c. Progesterone
Efeknya berhubungan dengan efek prostacyclin yang dijelaskan di atas.
2. Venous occlusion
Uterus yang membesar akan menekan vena-vena pada pelvis dan inferior vena cava. Karena itu, tekanan pada vena-vena tsb. meningkat. Peningkatan tekananan ini ditransmisikan ke vena di tungkai bawah dan daerah anogenital. Manifestasinya adalah edema pada tungkai bawah, varicose vein, hemorrhoid, dan peningkatan risiko deep vein thrombosis.
3. Supine hypotension
Karena uterus yang membesar akan menekan IVC, maka venous return berkurang. Ini akan mengurangi cardiac output dan pada sebagian kecil wanita (10%), akan menyebabkan arterial hypotension yang signifikan.
4. Peningkatan volume darah
Peningkatan aktivitas RAA system akan meningkatkan volume darah.
5. Peningkatan cardiac output
Cardiac output meningkat karena adanya peningkatan plasma volume (preload meningkat) dan penurunan resistensi vaskular sistemik (afterload berkurang). Namun, stroke volume relatif konstan, jadi peningkatan cardiac output lebih dikarenakan peningkatan heart rate. Peningkatan heart rate juga bisa dikarenakan hypotension.

169. The severe hypotension syndrome of pregnancy fulfills the following, except
A. it is associated with decreased blood pressure
B. it is due to acute occlusion of the IVC
C. increased heart rate is a frequent finding
D. it is rarely associated with cardiac standard
Jawab: D
Pembahasan:
Berdasar penjelasan di no. 169, maka A, B, dan C berhubungan dengan hypotension of pregnancy.

170. The most prominent cardiocirculatory change during pregnancy is
A. increase in systolic blood pressure
B. increase in heart rate
C. increase in left ventricular ejection fraction
D. increase in cardiac output
E. decrease in systemic vascular resistance
Jawab: D
Pembahasan:
Cardiac output meningkat 30%, karena:
Resistensi perifer berkurang
Uterine blood flow meningkat
Blood volume meningkat 40-45%
Heart rate meningkat 10-20%
Blood pressure tetap atau berkurang
Resistensi vaskular pulmonal berkurang
Tekanan vena sistemik meningkat
Sumber: Braunwald

For no. 171 – 173, refer to clinical scenario below
… y.o. woman came to the emergency department complaining of shortness of breath for one week. She was 6 month pregnant with her 5th child. Her former pregnancies are uneventful. Physical examination revealed she was dyspneic with an enlarged heart. A third heart sound was heard, systolic murmur over the tricuspid and mitral areas were heard.

171. ECG change in the woman may include all the following, except
A. 1st degree AV block
B.
C. Atrial premature beat
D. Ventricular premature beat
E. Peripheral …
Jawab: A
Pembahasan:
Kalau di kasus yang kita pelajari, paling dekat dengan kasus no. 171 ini adalah peripartum cardiomyopathy (PPCM), namun per definisi, seharusnya ibu ini tidak digolongkan sebagai penderita PPCM.
PPCM is a dilated cardiomyopathy (DCM), documented with echocardiographic left ventricular dysfunction occurring in the last month of pregnancy or within 5 months of pregnancy.
Pada DCM, perubahan EKG yang terjadi adalah sbb, namun ini tidak spesifik.
1. Sinus tachycardia
2. Poor R wave progression
3. Interventricular conduction delay
4. LBBB
5. Wide QRS complex  indicator of poor prognosis
6. Pathological anterior Q wave if patients have substantial LV fibrosis
7. Nonspecific ST segment and T wave abnormalities
8. Nonsustained ventricular tachycardia
9. Persistent supraventricular or ventricular arrhythmia
Atrial dan ventricular premature beat termasuk kategori no. 9

172. The most frequent clinical course in this prevention would be
A. congenital recovery of cardiac function
B. development of chronic heart failure
C. ventricular fibrillation and sudden death
D. no … or to depression with prolonged …
E. further clinical deterioration
Jawab: B
Pembahasan: Kurang jelas maksud pertanyaannya. Tapi dari 2006, pembahasannya begini:
Goal of therapy in DCM:
1. To relieve symptom
2. To prevent complications
3. To improve long-term survival
Opsi A salah, karena DCM bukan kelainan congenital (pada kasus ini, terutama)
Opsi B benar, karena paling sering, DCM akan berakibat pada perkembangan gagal jantung
Opsi C benar, tapi bukan yang paling sering
Opsi E belum tentu, karena jika dikontrol dengan obat-obatan, gejala klinis bisa membaik.

173. The management for this patient do not include the following
A. diuretics
B. digitalis
C. hydralazine
D. ACE inhibitor
E.
Jawab: D
Untuk pasien DCM yang sedang dalam keadaan hamil, ACE inhibitor dan ARB dikontraindikasikan karena dapat menyebabkan congenital malformation. Biasanya, pasien diberi kombinasi hydralazine dan nitrates sebagai vasodilator.

174. Postpartum hemodynamic change do not include one of the following condition
A. Increase in venous return
B. decrease in cardiac output
C. Rise in heart rate
D. low ventricular filling pressure
E.
Jawab: B
Pembahasan:
Perubahan hemodinamik postpartum:
Blood volume kembali normal
Cardiac output masih terelevasi hingga 48 jam karena peningkatan stroke volume yang disebabkan peningkatan venous return.
Sumber: Williams’ Obstetrics

175. Mitral stenosis in a pregnant woman is not associated with one of the following, except
A. Worsening in functional cardiac status
B. Occurrence of atrial fibrillation
C. Increased prematurity of newborn
D. Increased maternal mortality
E. Fetal growth retardation
Jawab: B
Mitral stenosis tends to worsen during pregnancy because of the increase in cardiac output coupled with the increase in heart rate; this shortens the diastolic filling time and exaggerates the mitral valve gradient. The onset of atrial fibrillation may precipitate acute pulmonary edema. A study of Canadian women has reported no maternal death, but 35 percent of pregnancies were associated with cardiac complications.

176. If lymphedema occurs in a patient, the most important fact that the patient has to know is
A. The problem is best treated with conservative therapy
B. The problem is treated with anticoagulants
C. The problem must be treated by antibiotics
D. The problem is treated by …
E. The problem is solved by surgical removal of the …
Jawab: A
Pembahasan:
Lymphedema is a condition of localized fluid retention caused by a compromised lymphatic system. Treatment for lymphedema varies according to the severity of edema and the degree of fibrosis of affected limb, including:
1. Bed rest and lymphedema sling
2. Compression
3. Manual decongestive massage
4. Isometric exercise
5. Home program (bandaging, elevation, exercise, skin care)

177. In rehabilitation program after acute myocardial infarction, a patient can … program
A. 2-4 days after AMI
B. 6-9 days after AMI
C. 1 month after AMI
D. 3-4 months after AMI
E. 4-9 months after AMI
Jawab: E
Cardiac rehabilitation program setelah MI dibagi menjadi 3-4 fase, tergantung status klinis pasien:
1. Phase I
Inpatient rehabilitation, usually lasting for the duration of hospitalization.
It emphasizes a gradual, progressive approach to exercise and an education program that helps the patient understand the disease process, the rehabilitation process, and the initial preventive efforts to slow the progression of disease.
In the US, it is oftend directed by Physical Therapy Department or a dedicated cardiac rehabilitation staff.
2. Phase II
Multifaceted outpatient rehabilitation, lasting 2-3 months.
Emphasizes safe physical activity to improve conditioning with continued behavior modification aimed at smoking cessation, weight loss, healthy eating, and other factors to reduce disease risk. Initiate an exercise prescription.
This refers to physician-supervised outpatient program. Patient exercise 3 times weekly for 3 months. The physician will monitor the electrocardiographic findings of the patient during exercise.
3. Phase III
Supervised rehabilitation, lasting 6-12 mo.
Establishes a prescription for safe exercise that can be performed at home or in a community service facility, such as a senior center or YMCA, and continues to emphasize risk factor reduction.
This phase refers to non-ECG monitored, medically-supervised, maintenance programme and is usually provided by the same facilities that provide phase II programs.
4. Phase IV
Maintenance, indefinite.

Exercise yang Dianjurkan:
a. Aerobic exercise
- Secara umum, pasien diharapkan berolahraga minimal 3x seminggu @ minimal 20 menit. Targetnya adalah mencapai 70-85% peak HR.
- Dengan asymptomatic ischemia, pasien diharapkan berolahraga dengan frekuensi dan durasi yang sama, namun targetnya adalah 70-85% peak HR.
- Dengan angina, pasien diharapkan berolahraga dengan frekuensi dan durasi yang sama, namun targetnya adalah 70-85% ischemic HR atau onset dari angina.
- Dengan claudication, pasien diharapkan berolahraga minimal 3x seminggu @ minimal 30 menit. Targetnya adalah berjalan untuk mendapatkan toleransi rasa nyeri.
- Pasien CAD yang sudah dipasang stent atau melakukan angioplasty dan pasien gagal jantung kelas NYHA I-III melakukan exercise yang sama dgn pasien CAD secara umum.
b. Resistance exercise
Dilakukan 2-3 x seminggu, dengan 12-15 repetisi. Intensitasnya adalah mencapai 30-50% repetition maximal weight.

Pasien boleh tidak ikut program lagi (masuk phase IV) setelah 6-12 bulan. Jadi, jawabnya E 

178. Which of the following regarding exercise in maintenance phase of rehabilitation in CAD is
TRUE
A. an improvement from aerobic exercise of certain muscle cells will met the needs of
Vocational or avocational activities
B. continuous ECG monitoring should always be used as it has shown to provide added safety during supervised exercise
C. during exercise, patient can monitor their HR by using carotid pulse
D. there are complications with exercise testing in elderly patients
E. the treadmill or bicycle exercise programs can meet all patients’ need
Jawab: A (jawaban 2006)

179. In the training phase of a rehabilitation program, a condition program is the physical capacity. The reconditioning program is done …
A. passive
B. passive-assistive
C. assistive
D. active
E. active-ressistive
Jawab: D (jawaban 2006)

180. In the training phase, the target heart rate for exercise training usually is …
A. 55-63% of the maximum heart rate
B. 65-75% of the maximum heart rate
C. 60-85% of the maximum heart rate
D. 85-95% of the maximum heart rate
E. 95-100% of the maximum heart rate
Jawab: C
Lihat penjelasan no. 177

MDE CVS 2007

1. Jawaban : A. Congenital heart disease
Alasan : udah jelas lah ya dari lahir
2. Jawaban : A. 1%
Alasan : About 0.8 percent of live births are complicated by a cardiovascular malformation (Braunwald ch 61)  mendekati 1 % ^_^
3. Jawaban : E. Closure of neural folds
Alasan : Langman sub bab formation and position of heart tube
4. Jawaban : B. Septum secundum
Alasan : ASD paling sering terjadi pada foramen ovale  bekas daerah septum secundum (Lilly hlm 380)
5. Jawaban : D. VSD
Alasan : Moore embyology hlm 312
7. Jawaban : A. Loud & high pitched
Alasan : Lilly hlm 383
8. Jawaban :
Alasan :
9. Jawaban : D. Size of the heart
Alasan : Slide minilecture radiology
10. Jawaban : B. TOF
Alasan : Langman bab 11
11. Jawaban : B. TOF
Alasan : Lilly hlm 393
12. Jawaban : C. 3rd aortic arch
Alasan : Moore embryology hlm 318
13. Jawaban : B. Apex of the heart upward
Alasan : moore embryology hlm 301
14. Jawaban : ???
Alasan harusnya jawabannya foramen ovale (bukan fossa ovale) tapi klo ga ada opsinya mentok2 pilih B aja...
15. Jawaban : C. Descending aorta
Alasan : Lilly hlm 384
16. Jawaban : E. Blood culture
Alasan : blood culture termasuk majojr criteria di modified duke criteria (Lilly hlm 222)
17. Jawaban : E. Staphylococcus aureus
Alasan : Lilly hlm 219
18. Jawaban : B. Staphylococcus aureus
Alasan : sama dengan no 17
20. Jawaban : C. TGA
Alasan : Braunwald hlm 1714

21. D. komplikasi endocarditis infective:
- glomerulonephritis
- CHF karena desturuksi dan rupture dari valve
- embolic stroke, purulent meningitis, dan cerebritis dengan microabses
Sedangkan TOF merupakan kelainan congenital
22. braunwald hal 1728. Cardiac surgery in patients with infective endocarditis
Indications
- Moderate to severe congestive heart failure cause by valve dysfunction
- Unstable prosthesis, prosthesis orifice obstructed
- Uncontrolled infection despite optimal antimicrobial therapy
- Unavailable effective antimicrobial therapy: endocarditis caused by fungi, Brucellae, pseudomonas aeurginosa
- Staphiloccocus aureus PVE with intracardiac complication
- Relapse of PVE after optimal therapy
- Fistula to pericardial sac
Relative Indication
- Perivalvular extension of infection, intracardiac fistula, myocardial abscess with persistent fever
- Poorly responsive S.aureus NVE
- Relapse of NVE after optimal antimicrobial therapy
- Culture negative NVE or PVE with persistent fever
- Large (>10mm) diameter hypermobile vegetation (with or without prior arterial embolism)
- Endocarditis caused by highly antibiotic-resistant enetrococci
Jadi jawabannya antara c/d
23. d.
a. rheumatic fever = terdapat polyarthralgia dan adanya riwayat dari pharyngitis
b. Kawasaki disease = terdapat perubahan pada mucosa (strawberry tongue), bilateral conjunctivae infection, cervical lymphadenopathy
c. scarlet fever = diawali pharyngitis  myalgia, petechiae, rash, tapi tanpa manifest ke jantung
24.c treatment sebenernya adalah mengeradicate penyebab IE dengan pemberian antibiotic.. tapi setelah itu, apabila pasien akan melakukan dental procedure, diberikan antibiotic prophylaxis.
25. E. option lain bisa sebagai komplikasi jika penyakit yang bersangkutan tidak ditreatment dan option C bisa sebagai manifestasinya..
Sedangkan option E, harusnya ditreatment bukan hanya (pada akhirnya ke) ventricle rate, tapi first medication itu dari anti arrhythmic drug adalah mentreat abnormalitas dari conduction system, dengan (dua diantaranya) menormalisasikan action potential rate, mencegat reentrant pathway dsb dari Seluruh pathway, sehingga terjadi normalisasi arus listrik  normalisasi rhythm yg berefek nantinya ke ventricular rate.
26. RHD.. major criteria : ada 2, minor : 1, + positif adanya GABHS infection ( 2 major or 1 major +2 minor dengan positif GABHS infection)
27. E. dari pathological jantung, dapat ditemukan aschoff bodies, bisa terdapat di endo, myo, atau epicardium
28. C. janeway lesion  small erythematous/ hemorrhagic macular non tender lesion on the palms and soles (sebagai tanda septic embolic signs)
29. d
30. C. untuk cek gabhs involvement  throat culture ato dengan titer antibody streptococcal termasuk antistreptolysin O, anti deoxyribonuclease-B, antihyaluronidase, dan streprozyme.
31. b
32. b. penicillin  inhibit sintesis cell wall
33.e. manifestasi dari RF : terjadi stenosis berupa penebalan atau kalsifikasi pada leaflet atau subleaflet yang berakibat reducing motion of leaflet, tapi gambaran echonya ya penebalan itu..
Terjadi regurgitasi karena melibatkan chorda tendinae (pemendekan excessive atau rupture) atau melibatkan leaflet berupa perforasi pada leaflet. Note: apabila terjadi rupture chordate baru terjadi leaflet prolaps
34. a
35. a polyarthritis : >=75%; carditis = 40-60%; chorea = 5-36%; erythema marginatum lalu subcutaneous nodule
36. a. salisilat punya pengaruh yang efektif pada inflamasi sendi, tapi untuk jantungnya diberikan corticosteroid
37. b. merupakan involuntary, irregular movement, fibirlatory muscle movement of tongue, characteristic spooning with external rotation of the hands and abolition of the movement with sleep.
40. a. adanya MS  suara tutupnya jadi kecil dan paling jelas dari mitral iu adalah di apex, sehingga yang terdengar jelas hanya s2.. terkadang bisa terdapat opening snap sebagai tanda kekakuan dari leaflet.
61. E
62. A
63. D
64. E
65. ga ada soal
66. ga ada soal
67. A
68. A
69. ga ada soal
70. ga ada soal
71. C
72. D
73. A
74. C
75. D
76. B
77. E
78. ga tau, sori
79. B
80. E (kayanya)

161. Ciri-ciri pericardial effusion …
A. boot shape
B.
C. tear drop
D. globular
E.
Jawab: D
Pembahasan:
Pada efusi pericardial tingkat sedang, siluet jantung pada radiography masih terlihat normal.
Pada efusi yang lebih besar, siluet jantung pada gambaran anteroposterior akan terlihat bulat (atau globular) dan mirip botol. Pada gambaran lateral akan terlihat pericardial fat pad sign (yaitu suatu lucency linear di antara dinding thorax dan permukaan anterior jantung, menunjukkan adanya pemisahan antara parietal pericardial fat dengan epicardium oleh cairan). Paru-paru terlihat oligemic (vaskular markings-nya sedikit meningkat.
Sumber: Braunwald

162. 60-year-old male presents with fever and chest pain. Physical examination shows pericardial friction rub. Laboratory examination shows increased white blood cell count and ESR.
Diagnosis: acute pericarditis

163. Typical presentation of the disease …
A. onset of pain crescendo
B. more comfortable in recumbent
C. abnormal S3 and S4
D. pulmonary congestion  in severe pericarditis
E. rub can last hours to days
Jawab: A
Pembahasan:
Soal no. 163 ini marupakan lanjutan soal no. 162, jadi masih membahas tentang acute pericarditis.
Sign and symptom:
1. Chest pain (pasien hampir selalu datang dengan keluhan ini), nyerinya severe. Kualitasnya rapid onset, terletak substernal (bisa juga pada dada kiri atau epigastrium kiri), dan biasa beradiasi ke lengan kiri atau ke trapezius ridge. Nyeri akan membaik jika duduk membungkuk dan akan memburuk jika berbaring.
2. Dyspnea
3. Fever
4. Cough
5. Hiccoughs (hiccups)
Pemeriksaan Fisik:
1. Pasien terlihat uncomfortable, anxious
2. Vital signs: low-grade fever, sinus tachycardia
3. Auskultasi jantung: ada friction rub yang terdiri atas 3 komponen. Komponen pertama terjadi pada ventricular systole, lalu pada early diastolic filling, dan pada atrial contraction. Bunyinya mirip suara berjalan pada crunchy snow. Rub paling terdengar pada lower left sternal border hingga cardiac apex, dan paling keras jika posisi pasien duduk membungkuk. Rub-nya dinamis, kadang muncul kadang menghilang.
Sumber: Braunwald
Dari Lilly disebutkan, onset dari chest pain biasanya crescendo.

164. Typical ECG changes…
A. inverted T wave with elevated ST segment
B. localized ST segment elevation
C. diffuse concave ST segment elevation
D. frequent PVCs
E. 1st degree AV block
Jawab: C
Pembahasan:
Electrocardiogram pada acute pericarditis menunjukkan temuan-temuan sbb:
1. Diffuse ST segment elevation (merupakan classic finding dalam perikarditis akut).
2. Depresi segmen PR  merupakan manifestasi yang lebih awal, biasanya terjadi sebelum ada rub maupun elevasi segmen ST
3. Sangat jarang terjadi elevasi ST yang berprogresi ke depresi segmen ST disertai inversi gelombang T.
Sumber: Braunwald

165. The following is true regarding the disease
A. the majority of cases are caused by …
B. TB pericarditis usually present with acute symptom
C. in most cases, it is associated with pericarditis
D. large pericardial effusion may occur with no symptom of pericarditis
E. Dressler syndrome used to be more common after viral infection
Jawab: D, evaluasi lagi opsi A dan C
Pembahasan:
Opsi A, belum tahu, karena tidak komplit
Opsi B salah, karena TB pericarditis biasanya presentasinya kronis
Opsi C g tahu, karena kurang jelas
Opsi D benar, efusi pericardial bisa dipresentasikan dengan nyeri dada maupun asymptomatic.
Opsi E salah, karena Dressler syndrome biasa terjadi setelah myocardial infarction, dan diduga merupakan penyakit autoimmune.

166. Chest radiograph, TRUE:
A. acute pericarditis: …
B. moderate pericardial effusion: …
C. the pericardial fat pad signs a hallmark sign in acute pericarditis
D. abnormal cardiac silhouette may be seen in …
E. … congestion is a signal of the presence of acute pericarditis
Jawab: ??
Pembahasan:
Opsinya g komplit!
Opsi A: pada acute pericarditis, radiography thorax biasanya normal
Opsi B: pada moderate effusion, radiography biasanya masih normal
Opsi C: pericardial fat pad sign merupakan ciri pericardial effusion, bukan pericarditis akut
Opsi D: abnormal cardiac silhouette biasanya terjadi pada pericardial effusion (berupa bottle-like appearance)
Opsi E: (mungkin pulmonary) congestion kadang menandakan acute pericarditis, tergantung etiologinya. Tetapi, jika idiopathic, biasanya tidak disertai congestion.

167. Regarding of the lab, which of the following area statement is true?
A. pericardial effusion appears as a hyperechoic separation between 2 pericardial layers
B. in acute idiopathic pericarditis, the ESR is normal
C. electrical alternant of the QRS complex is a characteristic sign in cardiac tamponade
D. elevation of cardiac markers is present in cardiac tamponade
E. diffuse ST segment elevation followed by Q wave is found in acute pericarditis
Jawab: B
Pembahasan:
1. Diagnosis Acute Pericarditis
a. Anamnesis: chest pain, dyspnea, fever, cough, hiccups
b. Physical examination: low-grade fever, sinus tachycardia, pericardial friction rub yang terdengar lebih keras saat inspirasi
c. Lab: modest elevation of WBC count, lymphocytosis pada idiopathic acute pericarditis, ESR is no more than modestly elevated pada idiopathic acute pericarditis
d. Radiography: pada idiopathic acute pericarditis, cenderung normal. Pada neoplasm, terlihat lymphadenopathy. Pulmonary infiltrates sering ditemukan pada tuberculous pericarditis. Jika disertai pericardial effusion, maka akan terlihat globular.
e. Electrocardiogram: diffuse ST segment elevation
f. Echocardiography: normal
2. Diagnosis Pericardial Effusion
a. Anamnesis: kadang mengeluhkan pericardial pain (seperti pericarditis) atau discomfort, tapi bisa juga asymptomatic.
b. Physical examination: normal jika efusinya sedikit/sedang. Namun, jika efusinya banyak, auskultasi akan menunjukkan muffled heart sounds. Cardiac impulse akan sulit dipalpasi. Ada tubular breath sounds jika bronchi mengalami kompresi oleh pericardium.
c. Radiography: globular, bottle-like
d. Electrocardiography: reduced voltage of QRS complex dan electrical alternans (amplitude kompleks QRS yang bervariasi, tinggi-rendah).
e. Echocardiogaphy: lucent separation between parietal and visceral pericardium, and the effusions can be regional and/or loculated
3. Diagnosis Cardiac Tamponade
a. Anamnesis: pasien mengeluhkan dyspnea, kadang ada pericardial pain atau discomfort, yang akan membaik jika duduk membungkuk (sitting and leaning forward). Terdapat pula gejala-gejala yang berkaitan dengan berkurangnya cardiac output, seperti fatigue, weakness, dizziness.
b. Physical examination: Beck’s triad (hypotension, muffled heart sounds, elevated jugular venous pressure), tachypnea, diaphoresis, cool extremities, peripheral cyanosis, depressed sensorium, yawning. Terdapat pulsus paradoxus. Cardiac impulse tidak ada atau berkurang. Terdapat friction rub.
c. Radiography: = pericardial effusion
d. Electrocardiography: = pericardial effusion
e. Echocardiography: lucent separation between parietal and visceral pericardium is circumferential (usually). Ada collapse dari RV pada saat early diastole dan collapse pada RA pada saat ventricular diastole (kalau tidak ada collapse, biasanya menunjukkan effusion, bukan tamponade).
Sumber: Braunwald

168. Which of the following statement is ECG changes typical of this disease (masih membicarakan pericarditis yang no. 162!)
A. ST segment elevation in all leads
B. deeply-inverted T waves resembling myocardial injury
C. localized convex ST segment elevation
D. frequent premature ventricular complex
E. prolonged PR interval
Jawab: A
Pembahasan: lihat no. 167

169. Management
A. treatment is not necessary in acute idiopathic pericarditis since it is a self-limiting disease
B. high dose of steroid recommended and great better outcome than NSAID
C. high dose of ibuprofen is drug of choice in pericarditis
D. narcotic analgesic and aspirin recommended in …
E. some cases … factors response after NSAID followed by surgical treatment
Jawab: C
Pembahasan:
Management dari pericarditis bertujuan:
- Deteksi etiologi yang memiliki implikasi terhadap management (misal, jadi harus ganti antibiotic)
- Deteksi effusion dan other echocardiographic abnormalities
- Meringankan symptom
- Treatment yang sesuai dengan etiologi yang spesifik
Acute idiopathic pericarditis merupakan self-limited disease tanpa komplikasi yang significan dan tanpa reccurence pada 70-90% pasien. Jika lab menunjukkan idiopathic acute pericarditis, maka NSAID (biasanya ibuprofen 600-800 mg p.o. tdd) hingga 2 minggu jika nyeri dada sudah tidak dirasakan lagi.
Jika pasien tidak merespon dengan baik pada awal pemberian NSAID, maka sebaiknya diopname untuk observasi dan tes tambahan.
Jika pasien merespon secara lambat, maka diperlukan tambahan analgesic narcotic dan/atau colchicines atau prednisone.
Pada pasien yang mengalami RECURRENT acute idiopathic pericarditis (15-30% dari pasien yang merespon secara memuaskan thd management yang disebutkan di atas), perlu dilakukan evaluasi untuk kemungkinan penyakit autoimmune, dan kadang (jarang) diperlukan biopsi pericardium. Pada kelompok pasien ini, diberikan lagi NSAID selama 2 minggu, lalu diberikan colchicines prophylaxis. Jika pasien tidak membaik, maka diberikan short course of prednisone ketika terasa gejala, namun ini tidak dilakukan secara kronis. Pericardiotomy bisa juga dilakukan, tapi hanya efektif pada sebagian kecil pasien.
Sumber: Braunwald

170. Sign and symptom
A. produce dull retrosternal pain
B. pain is severe and often sharp in acute pericarditis
C. pericardial friction rub is hallmark of chronic pericarditis
D. most pericardial friction rub are louder during expiration
E. relieved by lying down and taking deep breath
Jawab: B
Pembahasan: lihat no. 167

171. Which of the following statement is true regarding physical examination of cardiac tamponade?
A. arterial hypotension and increased JVP
B. prominent basal rales and dyspnea are the hallmark
C. decline in blood pressure during expiration
D. PMI can be seen easily
E. Kusmaull sign is a hallmark
Jawab: A
Pembahasan: lihat no. 167

172. Which of the following statement is true about pathophysiology of cardiac tamponade (CT)?
A. CT occurs when intrapericardial pressure is not equal to RA and RV diastolic pressure
B. In the presence of hypovolemia, CT may be more difficult to detect
C. Equalization of intrapericardial and ventricular filling pressure may lead to a small increase RV
D. Atrial fibrillation may occur during severe CT
E. Hemodynamic deterioration during tamponade is caused by RV failure
Jawab: E
Pembahasan:
Patofisiologi Cardiac Tamponade (CT)
CT dicirikan dengan suatu continuum yang dimulai dari efusi pericardium tanpa efek yang jelas yang berlanjut ke circulatory collapse. Ini tergantung pada tekanan di pericardium (yg meningkat karena efusi) dan kemampuan jantung untuk mengkompensasi peningkatan tekanan tersebut.
Volume cairan di pericardium biasanya hanya sedikit, jadi peningkatan jumlah cairan yang rapid, walaupun dalam jumlah kecil, dapat dengan cepat meningkatkan tekanan pericardium dan berpengaruh pada fungsi jantung. Sebaliknya, slowly accumulating effusion, walaupun jumlahnya besar, dapat ditolerir dengan baik.
Kompensasi jantung bergantung terutama pada respon sympathetic untuk meningkatkan heart rate dan kontraktilitas. Pada pasien yang meminum beta-blocker, maka respon ini minimal dan kompensasi jantung tidak maksimal.
Seiring dengan menumpuknya cairan pada pericardial cavity, akan terjadi peningkatan tekanan diastolic pada ruang-ruang jantung sehingga tekanannya sama dengan tekanan pad pericardial cavity (fenomena ini disebut equalization). Karena meningkatnya tekanan, maka volume darah di jantung akan berkurang (preload berkurang), menyebabkan berkurangnya stroke volume. Karena jantung kanan dindingnya lebih tipis dan kurang bisa beradaptasi terhadap peningkatan tekanan, maka peningkatan tekanan di jantung kanan lebih cepat daripada di jantung kiri (namun pada akhirnya akan mencapai tekanan yg sama, yakni tekanan pericardial cavity).
Kelainan hemodinamik lainnya:
1. Loss of y descent of RA (or systemic venous) pressure
Ini didasarkan pada konsep bahwa, pada severe CT, total heart volume tetap (tidak berkurang maupun bertambah, tidak dipengaruhi oleh kontraksi-relaksasi). Karena itu, darah hanya bisa mengalir ke jantung saat darah (yang tadinya ada di jantung) dipompa keluar. Karena itu, y descent, yang menggambarkan penurunan tekanan atrium setelah atrium berkontraksi, tidak tergambarkan.
2. Paradoxical pulse
Paradoxical pulse menggambarkan berkurangnya tekanan arteri sistemik secara abnormal (>10 mmHg) saat inspirasi. Pada CT (dan secara fisiologis), terjadi peningkatan systemic venous return saat inspirasi (sehingga systemic venous pressure berkurang). Ketika total volume jantung tetap, maka peningkatan venous return ini akan menyebabkan interventricular septum untuk shift to the left saat inspirasi, sehingga membuat LV menjadi sempit, dan stroke volume (LV pressure) berkurang secara abnormal. Karena itu, tekanan arteri sistemik pun berkurang saat inspirasi.
Jadi,
Opsi A salah, karena terjadi ekualisasi tekanan antara pericardial cavity dengan seluruh chamber jantung.
Opsi C salah, karena ekualisasi tekanan tidak meningkatkan volume RV, malah menguranginya. Ekualisasi tekanan meningkatkan tekanan RV hingga sama dengan tekanan pericardial cavity (yang tentunya sangat tinggi, mengingat ini adalah tamponade)
Opsi D salah, karena atrial fibrillation justru cenderung terjadi jika ada pembesaran atrium (substrat meningkat, lebih banyak jalur re-entry terbentuk, sehingga risiko terjadi AF meningkat). Pada CT, volume jantung tidak membesar.
Opsi E salah, karena cardiac tamponade menyebabkan berkurangnya cardiac output, sehingga lebih perubahan hemodinamis sistemik lebih disebabkan kegagalan LV, bukan RV.
Opsi B, jawaban yang paling mungkin; walaupun hypotension adalah salah satu tanda CT (lihat no. 167).

179. Which of the following is the most likely diagnosis?
A. chronic bronchitis and liver cirrhosis
B. congestive heart failure
C. alpha 1 antitrypsin deficiency
D. cor pulmonale
E. pericardial effusion
Jawab: ???
Tidak ada case…

180. Pulmonary circulation is similar to the systemic circulation in which of the following aspects?
A. The volume of blood in veins is similar in both system
B. The arteries serve as more important blood volume reservoirs in both system
C. The artery in both system are about the same length
D.
E.
Jawab: A
Pembahasan:
Opsi B salah, karena yang menjadi reservoir darah adalah vena.
Opsi C salah, karena arteri sistemik lebih panjang daripada arteri pulmonalis.
Jawaban yang paling mungkin dari 3 pilihan itu adalah A, namun jika di soal nanti ada pilihan D & E, cek lagi. Karena, pada vena sistemik, volume darah lebih besar (karena dia adalah reservoir) daripada vena pulmonalis.

MDE CVS 2008

1. Jawaban : D. Mesoderm
Alasan : keseluruhan jantung dibentuk dari splanchnic mesoderm (Moore embryology hlm 286)
2. Jawaban : E. Carniocaudal folding of the embryo
Alasan : Moore embryology hlm 292
3. Jawaban : C. Right ventricle
Alasan : bisa dilihat di gambaran anatomi jantung  right ventricle ada di anterior surface (Moore anatomy hlm 146)
4. Jawaban : D. Membranous VSD
Alasan : Moore embyology hlm 312
5. Jawaban : E. TGA
Alasan : pada TGA letak aorta dan pulmonary trunk jadi terbalik (Moore embryology hlm 314)
6. Jawaban : A. CKMB
Alasan : kelainan pada jantung yang biasanya diperiksa adalah CKMB dan cardiac specific troponin
7. Jawaban : A. Apolipoprotein A1
Alasan : Apo-A1 adalah penyusun utama HDL  semakin ↑ HDL  semakin ↓ risk for CAD yang ditanya : inverse/berbanding terbalik (harusnya Harper ada tapi males buka buku jadi dari inet...^_^)
8. Jawaban : B. AST peak in 24-48 hours after AMI and return to normal in 4-6 days
Alasan : Mild to moderate increases may be seen with vigorous excercise and muscle injury or in conditions such as acute pancreatitis and heart attacks
9. Jawaban : B. Troponin
Alasan : sama dengan no 6
10. Jawaban : B. Ckmb levels are normal in cases of cardiac ischemia
Alasan : CKMB akan naik bila terjadi infarct (penjelasan waktu lab act + Lilly hlm 183)
11. Jawaban : C. LDH pericardial fluid/serum ratio > 0.6
Alasan : ciri exudate  pericardial protein/serum >0.5 atau pericardial LDH/serum > 0.6 (Lilly hlm 344)
12. Jawaban : B. Therapy of amiodarone
Alasan : untuk menjaga stabilitas meskipun sudah sinus rhytm tetap perlu diberikan antiarrhytmia  amiodaron  ↓ sinud firing (Lilly 296, 428)
13. Jawaban : B. Loud 1st heart sound
Alasan : Lilly hlm 202
14. Jawaban : C. Janeway lesion
Alasan : Lilly hlm 220
15. Jawaban : E. Mitral Regurgitation
Alasan : MR bisa disebabkan oleh rupture chordae tendinae akibat blunt chest trauma (Baraunwald ch 62)
16. Jawaban : ???
Alasan : It is a consequence of shortening, rigidity, deformity, and retraction of one or both mitral valve cusps and is associated with shortening and fusion of the chordae tendineae and papillary muscles (Braunwald ch 61)  ini dr Braunwald tapi ga ada pilihan spesifik, kayaknya sih B
17. Jawaban : A. Thickening of chordae / leaflets
Alasan : Lilly hlm 199
18. Jawaban : B. Pulmonary hypertension
Alasan : Lilly hlm 216
19. Jawaban : E. Pericardial friction rub
Alasan : chest pain saat posisi tidur dan hilang saat duduk  tanda pericarditis (Lily hlm 337)
20. Jawaban : C. Coagulation
Alasan : Lilly hlm 177

21. C
Risk factor yang paling tinggi menyebabkan mortalitas: rokok, DM, alcohol, obesity
22. A
23. A
* 4-12 hours – 1-3 days = terjadi neutrophilic infiltrates
* 3-7 days – 7-10 days = well developed macrophage
* 10-14 days – 2-8 weeks = fibrous tissue formation
25. C. sebenernya bingung karena dari semua sumber, aschoff bodies itu bisa melibatkan semua lapisan cardium.. tapi kalo kita belajar dari tutorial, komplikasi tersering dari RHD tu kan valve stenosis ato regurgitant (dlm case ini diduga mitral involvement = karena ada dyspnea) jadi mikirnya kalo kena disitu, berarti lapisan endocardium..
26. A. Aschoff bodies = swollen eosinophilic collagen yang dikelilingi T lymphocyte
27. C.. uda jelas ya.
28. C
29. A. di robin hal 216,,epitheloid cells itu merupakan manifestasi dari hypersensitivity type 4 karena non degradable product seperti tubercle bacilli. Disekitarnya dikelilingi oleh collar lymphocyte.
30. b
31. C. pada orang DM, terdapat abnormalitas fungsi metabolism lipid juga dan enzim pemecah seperti Lipoprotein lipase.. hasilnya menunjukan increasing LDL dan VLDL, decreasing HDL, dsb.
32.d.
33. B. statin merupakan obat HMG CoA reductase..
34. E. berdasarkan alur produksi hormonal.. reninANG 1  ANG2  Aldosteron
35. B. salah satu indicator dari pelepasan renin adalah penurunan perfusi dan tekanan darah ke ginjal yang dalam hal ini bisa karena penurunan BP.. tapi jika BP sudah mendapat batas, maka terjadi feedback negative ke ginjal untuk stop produksi dari RAA system.
36.
37. D.
38. B. efeknya oleh Endothelin isoform 1 (ET-1), dan endothelin ini juga bisa dihasilkan selain oleh endothelium, juga oleh cardiac myocyte.
39.
40.?
61. -
62. -
63. -
64. B
65.-
66. E
67. C
68. B
69. B
70. B
71. A
72. A
73. D
74. B
75. B
76. -
77.-
78. D
79. A
80. C
81. C. anterior interventricular branch of coronary artery
Distribution of anterior IV branch: right and left ventricle and anterior two third of IVS
Moore,158

82. C. Left side in midclavicular line in the 5th ICS
Auscultation area of mitral valve is 5LICS(5th left intercostals space)
Moore, 168

83. E. in the wall of the RA near the opening of the superior vena cava
Normal heart rate controlled by SA node. This is location of SA node
Moore, 162

84. C. activate guanilate cyclase
Lily, 414

85. B. Captopril
The drug to prevent ventricular remodeling process: captoril. Karena obat ini akan menghambat produksi aldosterone sehingga efek bahayanya bisa terhindari. Efek buruk dari aldosterone adalah provoking hypertrophy and fibrosisi within myocardium

86. A. decreased potassium level
MOA Furosemide adalah loop diuretic yaitu menghambat NKCC2, the luminal Na/K/Cl transporter in thick ascending limb of Henle’s loop.
Transporter ini normalnya akan menyerap Na,K,dan Cl searah dari lumen ke sel-sel ascending limb,sekaligus menyerap air. Ketika traspoter ini dihambat tidak ada penyerapan air(dan Na,Cl, serta K)pembuangan K tinggihypokalemia
(katzung 10th,243)

87. D. Captoril
Kontra Indikasi Captopril:.
-Penderita yang hipersensitif terhadap captopril atau penghambat ACE lainnya (misalnya pasien mengalami angioedema selama pengobatan dengan penghambat ACE lainnya)
-Wanita hamil atau yang berpotensi hamil.
-Wanita menyusui
-Gagal ginjal

88. B. Increased of bradykinin level
Ingat penjelasan salah seorang dokter waktu lecture. Untuk mekanisme lebih jelasnya baca lagi ya

89. C. Digoxynpositive inotropic drug
90. B. Heparinanticoagulant effect
91.
92. E. Nifedipineblockage of Ca channel
93. D. Propanololcompetitive B-antagonist
94. E. Pulsatile arterial trauma

96. E. Thromboangitis Obliterans
Ciri khas: Heavy smoker dan painful ulcer in distal extremities
Lily, 361

97. C. Ischemia
Thromboangitis obliteran muncul dengan Triad Symptom:
-Distal arterial occlusionmenghasilkan claudication,yaitu exertional limb fatigue and pain cause by ischemia(inadequate supply to of blood to affected muscle)
-Raynold’s phenomenon
-Migrating superficial vein thrombophlebitis
Lily,361

98. E. Phlebitis
Lihat penjelasan nomor 97

99. D. Hemosiderin deposit

100. E. Angiography
Left arm hypertension and claudication in her limb masalah pada pembuluh darah extremitas pemeriksaannya adalah angiography

100)E claudication is a classic symptom of exertional limb fatigue and pain.usually occur in peripheral aterial disease(PAD),which may result in chronic occlusive arterial disease,with progressive stenosis & obstruction of blood flow.evaluation : duplex USG-assess the extent of arterial stenoses & corresponding reduction in blood flow.other imaging-MRA,CT-angiography-are obtained when revascularization procedure are planned (lilly;4th ed,pg 356-359)

101)E  Tuberculous pericardial effusions are typically exudative and characterized by a high protein content and increased leukocyte count, with a predominance of lymphocytes and monocytes.(American Heart Association-Circulation. 2005;112:3608-3616).
Nontuberculous bacterial(suppurative) pericarditis-fluid is a turbid exudates characterized by PMN leukocytes,increased LDH & decreased glucose.(braunwald;6th ed;pg 1854)

102)

103)A ECG pattern-diffuse ST segment elevation in most of ECG leads,usually with exception of aVR & V1.PR segment depression in several leads is often evident,reflecting abnormal atrial repolarization related to atrial epicardial inflammation.(lilly;4th ed;pg 338)

104) B most frequent symptoms of acute pericarditis are chest pain & fever-pain may be severe..pain typically sharp & pleuritic & positional(sitting & leaning forward often lessen the discomfort).dyspnea is common during acute pericarditis but is not exertional & probably result from a reluctance of patient to breath deeply because of pleuric pain.(lilly,4th ed;pg 337)

105)

106)A idiopathic/viral pericarditis is a self limited disease-runs in course in 1-3weeks-management-rest,analgesic & NSAIDs.recurrent pericardial pain-oral corticosteroid.(lilly,4th ed;pg 339)

107)E an intravenous drip containing isotonic saline or dextrose in water can be used to deliver supporting therapy (braunwald,6th ed,pg 1840)

108)may be B or CECG,always nonspecifically abnormal,T wave-low/flat/have general /local inversion.QRS n T wave voltage may be normal or reduced,interatrial block is common-P waves wider than 100ms n usually notched.
Constriction (especially chronic) may present deceptively as congestice failure,pleural effusion,RA thrombosis,even hepatic coma.CP resembles ,but is not HF;venous congestion resembles right-sided HF with appropriate compensatory response.
All cardiac diastolic pressures are nearly equilibrated as in cardiac temponade (braunwald,6th ed,pg 1850-1852)

109)

110) C ELECTROCARDIOGRAPHY-In acute pericarditis, the ECG typically shows ST-segment elevation in all leads, with an upward concavity of the elevation (so-called “smiling face”). The PR segment is depressed. Unlike myocardial infarction, there is no reciprocal change, and T waves are not inverted.12–15
In this situation, the differential diagnosis includes acute myocardial infarction and normal-variant repolarization abnormality. It is particularly important to distinguish pericarditis from acute myocardial infarction, because thrombolytic therapy could have disastrous effects in patients with pericarditis. Characteristic features of acute pericarditis, acute myocardial infarction, and early repolarization are summarized in Table 3. Examples illustrating the ECG differentiation of the three conditions are provided in Figure 2.16

Electrocardiographic Differentiation of Pericarditis
________________________________________
Acute pericarditis Acute myocardial infarction Early repolarization
ST-segment elevation in many leads, with no ST-segment depression Upward concave ST-segment elevation No T-wave inversion in leads with ST-segment elevation PR-segment depression Q waves during evolution ST-segment elevation in anatomically contiguous leads, with possible reciprocal ST-segment depression Upward convex ST-segment elevation T-wave inversion in leads with ST-segment elevation as myocardial infarction evolves No PR-segment depression May have Q waves during evolution ST-segment elevation in middle and left precordial leads, but may be widespread Upward convex ST-segment elevation May have T-wave inversion in leads with ST-segment elevation No PR-segment depression No Q waves


A. Acute pericarditis. The ST segment (long arrows) is elevated in all leads (universal elevation in contrast to the focal elevation in acute myocardial infarction), with no reciprocal change. The ST-segment elevation shows upward concavity (so-called "smiling face"). The PR interval (short arrow) is depressed because of inflammatory changes involving the atrial wall.

B. Acute myocardial infarction. The ST segment (long arrow) is elevated in leads II, III, and aVF, and depressed (short arrow) in leads I, aVL, and V1, V2, and V3 (focal elevation in segment of injury, with reciprocal ST-segment depression). The ST elevation is convex upward (tomb shape or so-called "sad face").

C. Early repolarization. ST-segment elevation (long arrow) is present in all leads, with no reciprocal depression. Peaked T waves (short arrow) are seen in the middle precordial leads. No Q waves are present
In cardiac tamponade, the ECG shows electrical alternans as the heart “floats” in relation to the recording leads. Chronic constrictive pericarditis presents with low voltage of the QRS complex and diffuse flattening or inversion of the T waves. Atrial fibrillation occurs in one third of patients with pericardial disease.
LABORATORY TESTS
Laboratory studies are useful for excluding other possible causes of symptoms and clarifying the underlying cause of pericarditis. Testing is individualized but frequently includes a complete blood cell count (CBC), an erythrocyte sedimentation rate (ESR), cardiac enzyme levels, and serum chemistries. Non-specific elevations in the CBC and ESR are common in patients with pericarditis. (American Academy of Family Physicians)
111)A a sharp early diastolic thrust is common especially in chronic constriction,corresponding to ventricular rapid filling.it coincides with loud,often palpable,abnorlmal S3,which sometimes has a ‘knocking’ quality.CP resembles,but is not HF.(braunwald,6th ed,pg 1851-1852)
112)A hypothesis-COPD,diagnosis:chest radiograph,ECG,echoCG,MRI,CT scan,radionuclide ventriculography(braunwald,6th ed,pg 1938)

113)B dilation of RV gives the heart a globular appearance,but right ventricular hypertrophy or dilation is not easily discernible on a plain chest radiograph.pulmonary arterial hypertension in patient with COPD has been shown to be related to width of right descending pulmonary artery.although there are numerous disorders that fall under the heading of COPD,the 2 largest components are emphysema and chronic bronchitis.(braunwald,6th ed,pg 1938-1939)

114)D management goals in COPD are ameliorate air flow obstruction and improve symptos,toavoid 2ndry complications,to maintain functional capacity & to improve the quality of life.drugs:anticholinergics,beta-blocker agonist,rheophylline,corticosteroids,digitalis,vasodilators,NO,ACE inhibitors,noninvasive ventilation(braunwald,6th ed,1941-1943)

115)

116)C PAH in COPD is due to multiple factors,include pulmonary vasoconstriction caused by alveola hypoxia,academia,and hypercarbia;the mechanical effects of high lung volume on pulmonary vessels;the loss of small vessels in vascular bed in regions of emphysema & lung destruction;ang increased of CO n blood viscosity from polycythemia secondary to hypoxia.of these causes,hypoxia is undoubtedly the most important & is associated with pathological changes that occur characteristically in peripheral pulmonary arterial bed.(braunwald,6th ed,pg 1940)

117)D pulmonary thromboembolism,as a single event or as repeated events,rarely leads to development of chronic pulmonary hypertension(braunwald,6th ed,pg 1949)

118)D vasodilators produced by endothelium include NO,prostacyclin,& EDHF(LILLY,4TH ED,144)

119)A lec note

120)C lecture note(cardiac rehabilitation)

161. Which of the following is the most likely diagnosis?
A. VSD
B. ASD
C. Aortic stenosis
D. Tricuspid regurgitation
E. Mitral valve prolapsed
Jawab: E
Pembahasan:
Karakteristik bunyi jantung pada penyakit-penyakit di atas adalah sbb:
Ventricular septal defect: harsh systolic murmur, middiastolic rumble
Atrial septal defect: RV heave, widened-splitted S2, middiastolic murmur at left lower sterna border
Aortic stenosis: coarse late-peaking systolic ejection murmur, parvus-tardus carotid pulse, S4, attenuated S2
Tricuspid regurgitation: systolic murmur at lower left sterna border which is augmented by inspiration
Mitral valve prolapse: midsystolic click, late systolic murmur

162. Which of the following is the most appropriate management for the patient?
A. Cardiac catheterization
B. Penicillin prophylaxis for dental procedure
C. Avoidance of strenuous activity
D. Beta blocker
E. Digitalis
Jawab: B
Pembahasan:
Mitral valve prolapse secara umum kondisinya benign sehingga kebanyakan pasien akan asymptomatic untuk sebagian besar masa hidupnya.
Komplikasi utama adalah endocarditis. Sehingga opsi B adalah jawaban paling tepat.

163. The heart disease that is present at the time of birth is known as …
A. congenital heart disease
B. cardiogenic shock
C. cardiovascular disease
D. coronary heart disease
E. acquired heart disease
Jawab: A
Pembahasan: jelas :-)

164. A 45-year-old man is admitted to the hospital with low grade fever, night sweat, fatigability, malaise, weight loss, and valvular insufficiency. There is also erythematous subcutaneous nodules about the tips of the digits and hemorrhagic retinal lesion. After examining the patient, the doctor in charge thought that the man suffered from subacute bacterial endocarditis. What is the common cause of the disease?
A. Staphylococcus aureus
B. Staphylococcus epidermidis
C. Streptococcus viridans
D. Streptococcus non hemolyticus
E. Streptococcus gamma haemolyticus
Jawab: C
Pembahasan:
Etiologi utama acute infective endocarditis adalah Staphylococcus aureus.
Etiologi utama subacute infective endocarditis adalah Streptococcus viridans, enterococci, fastidious gram negative bacteria. Yang ada di pilihan hanya Streptococcus viridans.

165. Blood culture of suspected subacute infective endocarditis patients is performed on blood agar and after incubation in 37 C for 24 hours, growth of some bacterial colony is observed. What is the colony morphology of such bacteria?
A. Diameter is 3 mm, non hemolytic
B. Diameter is 3 mm, hemolytic
C. Pinpoint colony, non hemolytic
D. Pinpoint colony, alpha hemolytic
E. Pinpoint colony, beta hemolytic
Jawab: D
Pembahasan:
Kemungkinan besar, bakteri yang ditemukan pada kultur adalah Streptococcus viridans (karena subacute infective endocarditis). Bakteri ini termasuk golongan alpha-hemolytic. Jadi jawabnya D.

166. To confirm an infective endocarditis, the doctor usually must have three positive blood cultures of the patient. From three blood samples drawn from three different venipuncture, except for a certain bacterium, only one positive sample is needed. What is the name of the bacterium?
A. Mycobacterium tuberculosis
B. Pseudomonas aeruginosa
C. Streptococcus pneumonia
D. Coxiella burnetti
E. Eikenela corrodens
Jawab: D
Pembahasan:
Criteria for Diagnosis of Infective Endocarditis
Major Criteria
Positive blood culture
Typical microorganism for infective endocarditis from two separate blood cultures
Viridans streptococci, Streptococcus bovis, HACEK group or
Staphylococcus aureus or community-acquired enterococci in the absence of a primary focus, or
Persistently positive blood culture, defined as recovery of a microorganism consistent with infective endocarditis from:
Blood cultures (≥2) drawn more than 12 hr apart, or
All of three or a majority of four or more separate blood cultures, with first and last drawn at least 1 hr apart
Single positive blood culture for Coxiella burnetii or antiphase I IgG antibody titer >1:800
Evidence of endocardial involvement
Positive echocardiogram (TEE advised for PVE or complicated infective endocarditis)
Oscillating intracardiac mass, on valve or supporting structures, or in the path of regurgitant jets, or on implanted material, in the absence of an alternative anatomical explanation, or
Abscess, or
New partial dehiscence of prosthetic valve, or
New valvular regurgitation (increase or change in preexisting murmur not sufficient)
Minor Criteria
Predisposition: predisposing heart condition or intravenous drug use
Fever ≥38.0°C (100.4°F)
Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, Janeway lesions
Immunological phenomena: glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor
Microbiological evidence: positive blood culture but not meeting major criterion as noted previously or serologic evidence of active infection with organism consistent with infective endocarditis
Sumber: Braunwald hal. 1718

For question no. 167-168, see the scenario below
Most of the bacteria adhere to the damaged endothelium and cause endocarditis. There is also a kind of bacteria that can cause endocarditis on intact endothelium.

167. What is the name of such bacteria?
A. Coxiella burnetti
B. Haemophilus influenza
C. Streptococcus alpha hemolyticus
D. Pseudomonas aeruginosa
E. Staphylococcus aureus
Jawab: E
Pembahasan:
Mekanisme terjadinya endocarditis pada endothelium utuh (intact) adalah sbb:
1. Pada orang yang tua (elderly), terjadi proses degenerasi pada katup, sehingga ada inflamasi. Inflamasi ini akan menginduksi terbentuknya berbagai adhesion molecules yang dapat membantu pelekatan leukosit ke katup; namun juga dapat membantu pelekatan mikroorganisme ke katup.
2. Pada intravenous drug users (IDU), hal yang sama terjadi.
Mikroorganisme yang mampu berlekatan dengan adhesion molecule yang diekspresikan adalah Staphylococcus aureus, karena bakteri ini memiliki microbial surface components recognizing adhesive matrix molecules (MSCRAMMs). Selain itu, S. aureus memiliki keunikan mampu membuat sel endothel menginternalisasi S. aureus sehingga di dalam sel endothel, S. aureus dapat melakukan multiplikasi. Akibatnya, sel endothel akan mengalami kematian, sehingga tidak lagi intact. Ketika endothel tidak lagi intact, sementara bakteri sudah berkumpul di sekitarnya, maka terjadi endocarditis.
Sumber Braunwald hal 1719

168. What is the bacterial product that facilitate bacteria adherence to the endothelium of the endocardium?
A. LPS
B. Hyaluronidase
C. Hemolysin
D. Clumping factors
E. Streptokinase
Jawab: D
Pembahasan:
Secara kolektif, molekul-molekul pada permukaan bakteri yang dapat membantu perlekatan ke endothelium disebut dengan microbial surface components recognizing adhesive matrix molecules (MSCRAMMs). Molekul ini ada beberapa jenis:
1. Glucan atau dextran, diproduksi oleh Streptococci. Fungsinya memediasi penempelan dengan fibrin, katup yang terluka, dan memfasilitasi perkembangan endocarditis.
2. Fim A protein, diproduksi oleh Streptococcus parasanguis, membantu penempelan dengan fibrin dan memfasilitasi perkembangan endocarditis.
3. Fibronectin receptor, diproduksi oleh Staphylococcus aureus, Streptococcus viridans, Streptococcus Group A, C, dan G, Enterococi, Streptococcus pneumonia, dan Candida albicans. Receptor ini akan berikatan dengan Fibronectin yg secara alami diekspresikan oleh sel endothel. Pelekatan akan memediasi pembentukan endocarditis.
4. Clumping factor, diproduksi oleh Staphylococcus aureus, akan memediasi penempelan bakteri ke thrombi yang dibentuk, dan, pada eksperimen, ke katup aorticus.
5. Glycocalyx dan slime (lendir) di permukaan S. epidermidis tidak membantu pelekatan, namun dapat membuat S. epidermidis lebih virulen dan menghindari host defense.
Sumber: Braunwald

169. A 15-year-old boy is admitted to the hospital because of fever, malaise, and migratory polyarthritis. After examining the patient, the doctor in charge suspected that the boy suffered from rheumatic fever. What is the bacteria most likely responsible for such disease?
A. Staphylococcus epidermidis
B. Staphylococcus aureus positive coagulase
C. Streptococcus beta haemolyticus group A
D. Streptococcus alpha haemolyticus
E. Haemophilus influenza
Jawab: C
Pembahasan:
Cukup jelas. Etiologi dari rheumatic fever adalah group A beta-hemolytic streptococci (GABHS).

170. A doctor in charge in Cardiology Ward performs pericardiocentesis to a patient suspected of chronic infective pericarditis and takes out some bloody fluid. What bacteria is the most likely cause?
A. Pseudomonas aeruginosa
B. Mycobacterium tuberculosis
C. Streptococcus pneumonia
D. Haemophilus influenza
E. Staphylococcus aureus
Jawab: B
Pembahasan:
Pilihan-pilihan lainnya adalah bacterial pericarditis, yang kemungkinan menunjukkan pus pada pericardial fluid-nya.




For question number 171 and 172, refer to the scenario below
A 62-year-old man comes to your clinic with exercise-induced angina. His serum cholesterol is 277 mg/dL, LDL 157, HDL 43, and triglyceride 170. He is overweight and has two risk factors for CAD. On cardiac catheterization, there is occlusion of left anterior descending and the origin of right coronary artery.

171. Which of the following process cause the disease above?
A. adventitial proliferation
B. injury to endothelium
C. formation of an intimal plaque
D. proliferation of smooth muscle cells
E. attraction of platelet to collagen microfibrils
Jawab: C
Pembahasan:
Berdasarkan keluhan (exercise-induced angina), anamnesis (2 faktor risiko untuk CAD), pemeriksaan fisik dan lab (overweight, hypercholesterolemia, dyslipidemia, hyperlipidemia), maka pasien mengalami CAD.
Pada CAD, terbentuk atherosclerosis pada dinding arteri koroner pada jantung. Proses pembentukannya diawali oleh kerusakan pada endothelium yang menyebabkan LDL dapat masuk ke dalam jaringan subintima. Ketika LDL masuk, ia akan dimodifikasi menjadi modified LDL melalui proses oksidasi atau glikasi. Modified LDL akan menginduksi pembentukan reseptor scavenger pada leukosit yang masuk ke dalam tunica intima sehingga leukosit akan meng-engulf modified LDL. Engulfment ini akan mengubah leukosit (macrophage) menjadi foam cells. Foam cells sendiri mampu mensekresikan cytokine dan growth factor. Cytokine akan menginduksi migrasi sel otot polos dari tunica media ke intima. Growth factor akan menginduksi proliferasi sel otot polos tsb. Sel otot polos akan mensekresikan extracellular matrix (ECM). Proliferasi sel otot polos dan sekresi ECM akan menyebabkan penebalan lokal dari dinding pembuluh darah, menyebabkan oklusi.
Jadi, kesimpulannya, proses yang menyebabkan CAD adalah pembentukan plaque pada tunica intima.
Opsi yang lain tidak cukup untuk secara mandiri menyebabkan CAD.

172. Which of the type of arteries involved in the above condition?
A. Conducting
B. Distributing
C. Arterioles
D. Metarterioles
E. Capillaries
Jawab: B
Pembahasan:
Histologi Arteri
Arteri ada 3 macam:
1. Elastic/conducting artery
a. Diameter > 1 cm
b. Contoh: aorta, bracicephalic artery, common carotid artery, subclavian artery, pulmonary artery, common iliac artery
c. Fungsi utamanya adalah membantu mendorong darah ketika ventricle sedang relaksasi.
d. Tunica intima terdiri atas endothel, basal membrane, dan internal elastic lamina yang tidak utuh.
e. Tunica media terdiri atas smooth muscle, banyak elastic fibers, dan external elastic lamina yang tipis.
f. Tunica adventitia terdiri atas collagen dan elastic fibers.
2. Muscular/distributing artery
a. Diameter 0.1 – 1 cm
b. Contoh: brachial artery, radial artery
c. Fungsi utamanya untuk menentukan kecepatan aliran darah karena kemampuan konstriksi dan dilatasinya sangat tinggi
d. Tunica intima terdiri atas sel endothel, basal membrane, dan internal elastic lamina yang tipis
e. Tunica media terdiri atas banyak smooth muscle cells, sedikit elastic fibers, dan external elastic lamina yang tebal
f. Tunica adventitia terdiri atas collagen fiber dan elastic fibers.
3. Arteriole
a. Diameter 10-100 μm
b. Tunica intima terdiri atas endothel, basal membrane, dan internal elastic lamina
c. Tunica media terdiri atas smooth muscle cells, sedikit elastic fibers, tanpa external elastic lamina.
d. Tunica adventitia terdiri atas collagen dan elastic fibers.
Arteri koroner memiliki diameter < 1 cm, namun masih dapat terlihat jelas. Selain itu, kemampuan vasokonstriksi dan dilatasinya tinggi, sehingga termasuk muscular/distributing artery.

173. A 45-year-old woman came with painful, tender, cord-like structure with associated redness and swelling as chief complaint. Which of the following normal structures from damaged organ above?
A. Tunica intima has pericytes
B. Tunica intima has thick internal elastic lamina
C. Tunica media has reticular and elastic fibers
D. Tunica media has thick external elastic lamina
E. Tunica adventitia has smooth muscle cells
Jawab: kurang tahu, tapi kalau di buku 2006, dijawab D
Pembahasan:
Pembahasan 2006 juga:
Kemungkinan besar, arteri yang dimaksud adalah arteri muscular karena berada di antara jantung dan organ yang akan divaskularisasi.
Opsi A salah, karena pericyte hanya dimiliki oleh kapiler
Opsi B salah, karena tunica intima dari muscular artery memiliki internal elastic lamina yang tipis.
Opsi C salah, karena tunica media dari muscular artery hanya dibentuk oleh elastic fiber dan otot polos.
Opsi E salah, karena (di vaskular jenis apa pun) adventitia hanya terdiri atas collagen dan elastin
Opsi D benar, karena pada muscular artery, tunica medianya memiliki external elastic lamina yang tebal.

For question number 177 and 178, refer to the options below.
A. Decrease pulmonary vascular markings
B. Hilar alveolar infiltrats and widening of hilum
C. Cephalization
D. Revised comma sign

177. A man with a history of cardiac enlargement was confined for 7 days. Today, he is complaining of dyspnea again and chest X-ray reveals pulmonary congestion.

178. A middle-aged man smoker admitted to the hospital due to setting or worst chest pain. Based on x-ray, doctors’ conclusion was pulmonary edema.

Pembahasan tentang radiografi (dari jawaban 2006, maaf saya g nemu..):
- Decreased pulmonary vascular markings disebabkan oleh penurunan aliran darah pada arteri pulmonalis, biasanya karena ada block pada arteri tersebut. Contoh penyakitnya adalah pulmonary stenosis, TOF (karena ada pulmonary stenosis), pulmonary atresia.
- Hilar alveolar infiltrates disebabkan adanya alveolar edema karena congestive heart failure.
- Cephalization adalah redistribusi aliran darah dari vena pulmonalis untuk paru-paru lobus inferior ke lobus yang superior (normalnya, lobus yang inferior mendapat lebih banyak aliran). Ini biasa ditemukan pada congestion juga, namun tipe congestion yang lebih berat daripada hilar alveolar infiltrate.
Pada no. 177, jawabnya kemungkinan C, karena pada kasus ada cardiac enlargement, yang mengindikasikan gagal jantung confestif yang sudah lebih parah.
Pada no. 178, jawabnya kemungkinan B, karena ada pulmonary edema yang belum terlalu parah.

For number 179 and 183, refer to the options below.
A. MRI
B. CT scan
C. Nuclear medicine
D. Echocardiography
E. Conventional radiography of the chest

179. Abnormal of the costa sternum
180. Evaluation of hemodynamics of the heart

Pembahasan modalitas imaging untuk jantung (dari 2006 juga):
MRI digunakan untuk melihat jaringan lunak (darah maupun jaringan) pada berbagai bidang.
CT scan digunakan untuk melihat jaringan pada sumbu melintang tubuh.
Nuclear medicine berkaitan dengan penyuntikan zat radioaktif (kontras) untuk melihat uptake dari jaringan yang ditarget. Pada jantung, bisa digunakan untuk melihat fungsi myocardium.
Echocardiography paling baik digunakan untuk meng-assess fungsi jantung. Biasa melihat fungsi hemodinamik jantung jika dikombinasikan dengan Doppler, bisa melihat pergerakan katup, kontraksi jantung, dll.
Radiography thorax dapat melihat siluet jantung dan paru, vaskular markings, serta tulang-tulang pada thorax.
Jadi, jawaban no. 179 adalah E dan jawaban no. 180 adalah D.