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