WorksheetsBGHMC CV Module 2025 Quiz A
Total questions: 50
Worksheet time: 25mins
A 62-year-old man had a drug-eluting stent placed for NSTEMI 3 months ago. He’s on aspirin + ticagrelor. He now requests elective laparoscopic cholecystectomy for biliary colic. Best plan?
Proceed; continue aspirin, stop ticagrelor 24 h preop
Proceed; stop both antiplatelets 5 days preop
Proceed with cangrelor bridging after stopping ticagrelor
Delay elective non-cardiac surgery until at least 12 months after DES for ACS
Proceed under neuraxial anesthesia to reduce cardiac risk
A 74-year-old with symptomatic severe aortic stenosis (AVA 0.7 cm², mean gradient 48 mmHg) is scheduled for elective colonoscopy for anemia workup. He is dyspneic at rest. Best anesthetic strategy?
Propofol MAC with nasal cannula; treat hypotension with ephedrine
Defer non-urgent procedure and refer for valve intervention/optimization first
Ketamine MAC to preserve SVR
GA with LMA; liberal PEEP to reduce LV preload
Spinal anesthesia to avoid myocardial depression
A 45-year-old with obstructive HCM (dynamic LVOT gradient) develops septic hypotension during colectomy (MAP 55, HR 112). Best vasopressor?
Epinephrine infusion
Dobutamine infusion
Phenylephrine infusion
Norepinephrine infusion
Ephedrine boluses
A 78-year-old with CKD (eGFR 25) on apixaban for AF has a hip fracture requiring fixation today; last dose 6 h ago. Best reversal strategy before neuraxial anesthesia is considered?
Protamine
Vitamin K + FFP
4-factor PCC and avoid neuraxial
Idarucizumab
Desmopressin
A 59-year-old with LBBB needs ischemia evaluation before vascular surgery; poor METs. Best noninvasive test?
Exercise treadmill ECG
Dobutamine stress echo
Vasodilator nuclear perfusion imaging
Stress echo with exercise
Coronary calcium score
A 66-year-old with controlled HTN, RCRI = 0, and poor functional capacity (<4 METs) is scheduled for inguinal hernia repair. No cardiac symptoms. Best next step?
Cancel until stress test negative
Start high-dose β-blocker day before
Coronary CTA
Proceed to surgery without further testing
Start ACE inhibitor morning of surgery
A pacemaker-dependent patient (DDD) presents for shoulder arthroscopy with monopolar cautery. A magnet is available. Best perioperative device plan?
Place magnet over device and proceed—no further steps
Preop interrogation and temporary reprogramming to asynchronous pacing
Disable all pacing with magnet
No change; bipolar cautery only is enough
Remove the pacemaker lead sensing via magnet
A patient with an ICD (not pacer-dependent) needs laparotomy above the umbilicus with monopolar cautery. Best plan?
Proceed; magnet will convert to asynchronous pacing
Proceed without change; pads are unnecessary
Deactivate tachyarrhythmia therapies preop, place external defib pads, and use magnet as backup
Turn off brady pacing but maintain shocks
Switch to bipolar cautery only; no programming changes
A 38-year-old with WPW develops new-onset AF with RVR (HR 180) in the OR; BP 120/70; stable. Best treatment?
A. Adenosine
B. Diltiazem
C. Procainamide
D. Esmolol
E. Amiodarone bolus (first-line)
A 68-year-old on lisinopril for uncomplicated HTN is scheduled for total knee arthroplasty. Best ACE-i plan?
Continue morning of surgery to avoid rebound HTN
Hold morning of surgery to reduce refractory hypotension risk
Stop 72 h preop to avoid AKI
Switch to ARB morning of surgery
Give half-dose morning of surgery
A 70-year-old with moderate aortic regurgitation undergoes open AAA repair. Hemodynamics worsen after increasing PEEP from 5 – 12 cmH2O. Mechanism?
Decreased RV afterload
Increased coronary perfusion pressure
Reduced LV preload with bradycardia worsening regurgitant fraction
Improved forward flow via reduced afterload
Reduced LV wall stress and improved EF
A 55-year-old with cardiac tamponade from malignancy needs urgent pericardial window. Best induction plan?
Propofol + high PEEP to improve venous return
Ketamine with spontaneous ventilation
Etomidate + large fentanyl bolus + PEEP
Sevoflurane inhalational induction with N2O
Spinal anesthesia
A 47-year-old with severe pulmonary hypertension (mPAP 45, RV dysfunction) presents for laparoscopic appendectomy. Best intraop hemodynamic target?
Hyperventilation to PaCO2 25 mmHg
Avoid hypoxia, hypercarbia, acidosis
Large fluid boluses to raise CVP >20
High PEEP to offload RV
Phenylephrine as first-line for any hypotension
You are asked to start perioperative β-blocker therapy in a vascular patient with no prior use, two days preop. Best approach?
Load with metoprolol 200 mg on the morning of surgery
If indicated, initiate weeks in advance with careful titration
Start morning of surgery and titrate to HR 50
Avoid β-blockers in vascular surgery
Start esmolol infusion night before surgery
During one-lung ventilation, SpO₂ drops from 98% → 88%. FiO₂ is 1.0. Best next step to improve oxygenation consistent with HPV physiology?
Increase sevoflurane from 1.0 – 2.0 MAC
Apply CPAP to non-dependent lung or PEEP to dependent lung after recruitment
Switch to N₂O–O₂ mixture
Start nitroprusside to reduce HPV
Hyperventilate to PaCO₂ 25 mmHg
A 60-year-old with severe AS becomes hypotensive after induction (MAP 45). Best immediate vasopressor?
Epinephrine
Dopamine
Phenylephrine
Dobutamine
Isoproterenol
A 72-year-old with moderate MS develops AF with RVR (HR 150) during hip surgery; BP 100/60. Best initial therapy?
Amiodarone for pharmacologic conversion
Rate control with β-blocker or diltiazem if LV function preserved
Adenosine
Immediate synchronized cardioversion (hemodynamically stable)
Procainamide
A 58-year-old with recent DES for stable CAD 8 months ago needs colon resection for cancer (cannot delay). Best antiplatelet strategy?
Stop aspirin and clopidogrel 7 days preop
Continue aspirin and stop clopidogrel 5 days prep
Stop clopidogrel 24 h preop
Continue DAPT through surgery
Stop aspirin 3 days preop; continue clopidogrel
Which ventilator change most increases RV afterload in a COPD patient with pulmonary HTN?
Lowering tidal volume
Raising mean airway pressure/PEEP excessively
Increasing FiO2
Reducing I:E from 1:2 to 1:3
Adding pressure support during controlled ventilation
You place a PA catheter in a patient with acute MR. Which tracing change is most characteristic?
Giant A wave in wedge
Tall V waves in wedge pressure
Blunted Y descent in RA
Kussmaul sign
Large cannon A waves
A 63-year-old with ischemic cardiomyopathy (EF 25%) requires open colectomy. Which induction plan best balances hemodynamics?
High-dose propofol bolus
Etomidate-based induction with opioid blunting and vasopressor ready
Thiopental + N2O
Ketamine + high PEEP
Spinal anesthesia with heavy bupivacaine
During carotid endarterectomy under GA, sudden ST depression and hypotension occur. Best immediate step?
Large fluid bolus only
Treat as supply–demand mismatch
Give esmolol and phenylephrine to HR 40 regardless of BP
Start nitroprusside
Stop surgery and extubate
A 50-year-old with HFrEF on sacubitril/valsartan presents for surgery. Which periop risk is most typical vs ACE-i?
Hypertension refractory to treatment
Hypotension
Bradycardia
Hyperkalemia only
Worsened diastolic function
A patient on dabigatran (CrCl 35) has life-threatening bleeding after regional block. Best reversal?
4-factor PCC
Idarucizumab
Andexanet alfa
Vitamin K
FFP
A 54-year-old with severe MR needs laparoscopic cholecystectomy. Which targets are best?
Slightly higher HR, maintain preload, reduce afterload
Very low HR to maximize filling
High afterload to improve coronary perfusion
Low preload and high PEEP
Avoid volatile agents
In a patient with tamponade, which RA waveform change is expected?
Prominent Y descent
Blunted Y descent
Kussmaul sign
Cannon A waves
Giant V waves
A 70-year-old with bioprosthetic aortic valve (implanted 5 years ago) presents for dental extraction. Endocarditis prophylaxis?
None indicated
Give prophylaxis
Only if poor dentition
Only if prior endocarditis
Only if within 6 months of implantation
A 64-year-old with diastolic dysfunction (HFpEF) undergoes open hernia repair. Sudden hypotension with small fluid responsiveness, high BP variability with PPV 8%. Best initial therapy?
Large fluid bolus
Phenylephrine
Esmolol to HR <50
Nitroprusside
Dobutamine
Which change most decreases coronary perfusion pressure intraop?
Increasing SVR
Vasodilation
Mild bradycardia
Reducing PEEP
Decreasing HR
A 58-year-old with pulmonary HTN and RV failure becomes hypotensive. Best initial vasopressor/inotrope?
Phenylephrine
Norepinephrine
Esmolol
Nitroglycerin
Milrinone as first-line bolus
A patient on ticagrelor requires urgent craniotomy for epidural hematoma. Best strategy?
Platelet transfusion reliably reverses ticagrelor
Bentracimab
Desmopressin completely reverses
Vitamin K
tPA
In severe MS, which intraop event most threatens hemodynamics?
AF with RVR
Mild anemia
Decrease in SVR
Mild hypercarbia
Slight bradycardia
For a patient with recent PCI who must stop clopidogrel, which short-acting agent can bridge P2Y12 inhibition up to the time of incision?
Heparin infusion
Cangrelor
Cilostazol
Eptifibatide infusion post-op only
Aspirin bolus
A 76-year-old with severe AS develops new LBBB and hypotension after cross-clamping the aorta. Best immediate monitor/step?
Troponin now
Place arterial line and treat hypotension
Remove cross-clamp immediately
Give amiodarone
Increase volatile to 2 MAC
You suspect dynamic LVOT obstruction after aggressive diuresis in an elderly patient with small LV cavity; TEE shows systolic anterior motion. Best acute therapy?
Nitroglycerin
Phenylephrine and volume
Dobutamine
Milrinone
Increase PEEP
A 67-year-old with aortic regurgitation under GA becomes profoundly bradycardic (HR 40) but normotensive. What’s the main risk?
Coronary steal
Increased diastolic time
RV ischemia
Alkalosis
Hyperkalemia
A 55-year-old with EF 30% requires major abdominal surgery. Which volatile agent property is most favorable?
Halothane preserves baroreflex
Modern volatiles allow titratable afterload reduction but must avoid hypotension
N2O reduces PVR and is ideal
Desflurane sympathetic blunting at any dose
Sevoflurane contraindicated in LV dysfunction
A patient with CRT-D needs TURP (below umbilicus) with bipolar cautery. Best device plan?
Disable therapies anyway
No routine reprogramming
Place magnet to asynchronous mode
Turn off pacing
Replace with temporary pacer
During prone spine surgery, PPV is 18% with controlled ventilation (no arrhythmia), Vt 6 mL/kg, PEEP 5, FiO2 0.5. MAP 70. CVP 10 after turning prone. Interpretation?
Not fluid responsive
Likely fluid responsive if criteria met
Indicates RV failure
Indicates need for vasodilator
Indicates pneumothorax
The oxygen delivery (DO2) of a septic patient is low with Hb 7, SaO2 100%, CO 3 L/min. Which change most increases DO2?
Raise FiO2 from 0.6 → 1.0
Transfusion
Hyperventilation
Decrease PEEP
Start nitroglycerin
A patient with mechanical mitral valve on warfarin presents for urgent laparotomy with INR 2.8. Best immediate reversal to allow surgery?
Vitamin K only
4-factor PCC + IV vitamin K
FFP only
Protamine
Idarucizumab
TEE during hypotension shows a small LV cavity, hyperdynamic walls, and no regional wall motion abnormality. Best cause and treatment?
MI; give nitro
Relative hypovolemia/low preload
RV infarct; start nitro
Tamponade; start PEEP
PE; give thrombolysis
A patient with moderate MR is undergoing shoulder surgery in beach-chair position. MAP measured at the arm is 65. The brain is 30 cm above the transducer. Cerebral perfusion pressure is approximately:
65 mmHg
~42 mmHg
~58 mmHg
~35 mmHg
~75 mmHg
After spinal anesthesia, a patient with severe AS becomes hypotensive and tachycardic. Best immediate step?
Trendelenburg and fluids only
Phenylephrine and treat tachycardia
Ephedrine only
Atropine and nitro
High-flow O₂ only
A 52-year-old with Brugada pattern on ECG needs appendectomy. Which drug is most concerning?
High-dose Fentanyl
High-dose Propofol
High-dose Etomidate
High-dose Phenylephrine
High-dose Rocuronium
For a patient with severe pulmonary HTN on chronic sildenafil and inhaled treprostinil, which agent is preferred to treat systemic hypotension?
Phenylephrine
Norepinephrine
Esmolol
High-dose vasopressin as first-line
Nitroglycerin
A patient with HOCM on β-blocker is persistently hypotensive (MAP 55) after induction despite phenylephrine and volume. Next best step?
Start dobutamine
Add vasopressin
Increase sevoflurane to deepen anesthesia
Start nitroprusside
Switch to ephedrine
During TEE, you suspect acute PE. Which immediate finding supports this?
Hyperdynamic LV with low gradient
Dilated RV with septal flattening and McConnell sign
Small RV with hypertrophy
Large pericardial effusion
Severe MS
A 65-year-old with CKD and NSTEMI 1 month ago (managed medically, no stent) needs urgent colectomy for bleeding cancer. Best periop troponin strategy?
No troponins periop
Obtain baseline and postoperative troponins for surveillance
Only if symptomatic
Daily ECGs only
Echo only
During laparoscopic surgery, a patient with fixed-rate VVI pacemaker develops profound bradycardia with insufflation. Magnet is placed but HR remains 40. Most likely reason?
Magnet disables all pacing
Not all pacemakers convert to asynchronous pacing with a magnet
Magnet always increases HR
Magnet turns on ICD therapies
Magnet converts to DDD mode
