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WorksheetsBGHMC CV Module 2025 FINAL EXAM
Total questions: 100
Worksheet time: 1hrs 15mins
A 62-year-old man had a drug-eluting stent (DES) placed for NSTEMI 3 months ago. He is on aspirin and ticagrelor and now requests elective laparoscopic cholecystectomy. Which is the best plan?
Delay elective non-cardiac surgery until at least 6 months after DES for ACS.
Proceed with surgery but stop ticagrelor 24 hours prior while continuing aspirin.
Proceed with surgery but stop both antiplatelet agents 5 days preoperatively.
Delay elective non-cardiac surgery until ticagrelor can be switched to clopidogrel.
Delay elective non-cardiac surgery until at least 12 months after DES for ACS.
A 74-year-old with symptomatic severe aortic stenosis (mean gradient 48 mmHg) is scheduled for elective colonoscopy for anemia workup and is dyspneic at rest. What is the best anesthetic strategy?
Defer the non-urgent procedure and refer for valve intervention first.
Proceed with ketamine-based monitored anesthesia care.
Proceed with spinal anesthesia to avoid myocardial depression.
Proceed with general anesthesia and liberal PEEP to reduce preload.
Proceed with propofol-based monitored anesthesia care.
A 45-year-old with obstructive hypertrophic cardiomyopathy develops septic hypotension during colectomy with a MAP of 55 mmHg and HR 112 bpm. Which is the best vasopressor?
Phenylephrine infusion to increase systemic vascular resistance.
Epinephrine boluses to augment heart rate and blood pressure.
Dobutamine infusion to improve inotropy and stroke volume.
Norepinephrine infusion to support both SVR and contractility.
Epinephrine infusion to support contractility and heart rate.
A 78-year-old with CKD (eGFR 25) on apixaban for atrial fibrillation requires urgent hip fracture fixation. Last dose was 6 hours ago. What is the best reversal strategy before considering neuraxial anesthesia?
Administer 4-factor PCC and avoid neuraxial techniques.
Administer protamine sulfate to reverse factor Xa activity.
Administer idarucizumab to reverse the direct thrombin inhibitor.
Administer vitamin K and fresh frozen plasma.
Administer desmopressin to improve platelet function.
A 59-year-old with LBBB and poor functional capacity needs an ischemia evaluation before vascular surgery. Which noninvasive test is best?
Vasodilator nuclear perfusion imaging.
Dobutamine stress echocardiography.
Coronary artery calcium scoring via non-contrast CT.
Standard exercise treadmill electrocardiogram testing.
Standard exercise treadmill stress echocardiography.
A 66-year-old with controlled hypertension, RCRI 0, and poor functional capacity (<4 METs) is scheduled for inguinal hernia repair without cardiac symptoms. What is the best next step?
Proceed to surgery without further cardiovascular testing.
Start an ACE inhibitor on the morning of surgery for protection.
Order a preoperative coronary CTA to assess for occult disease.
Cancel the procedure until a negative stress test is obtained.
Start a high-dose beta-blocker on the day before surgery.
A pacemaker-dependent patient with a DDD device presents for shoulder arthroscopy with monopolar cautery. A magnet is available. What is the best perioperative device plan?
Arrange preoperative interrogation and reprogram to an asynchronous pacing mode.
Proceed after ensuring only bipolar cautery will be used by the surgeon.
Place the magnet over the device to convert it to a VVI mode.
Place the magnet over the device to disable sensing and proceed.
Disable all pacing functions with the magnet and use external pacing.
A patient with an ICD who is not pacer-dependent needs a laparotomy above the umbilicus with monopolar cautery. What is the best plan?
Deactivate tachyarrhythmia therapies preoperatively and place external defibrillator pads.
Proceed with surgery as the magnet will convert the device to asynchronous pacing.
Proceed with surgery after switching all cautery to bipolar mode.
Proceed without changes as external pads are unnecessary in this case.
Turn off bradycardia pacing functions but maintain the shock therapies.
A 38-year-old with WPW develops new-onset atrial fibrillation with rapid ventricular response at 180 bpm in the OR. Blood pressure is 120/70. What is the best treatment?
Procainamide to slow accessory pathway conduction.
Esmolol to control the ventricular rate.
Diltiazem to block AV nodal conduction.
Adenosine to terminate the arrhythmia.
Amiodarone as the first-line antiarrhythmic.
A 68-year-old on lisinopril for uncomplicated hypertension is scheduled for total knee arthroplasty. What is the best plan for the ACE inhibitor?
Hold the morning dose to reduce refractory hypotension risk.
Switch to an equivalent angiotensin receptor blocker dose.
Continue the full dose to prevent rebound hypertensive events.
Administer a reduced half-dose on the morning of surgery.
Stop the medication 72 hours prior to avoid renal injury.
A 70-year-old with moderate aortic regurgitation undergoes open AAA repair. Hemodynamics worsen after increasing PEEP from 5 to 12 cmH2O. What is the most likely mechanism?
PEEP reduced LV preload and worsened the regurgitant fraction.
PEEP improved forward flow by reducing systemic afterload.
PEEP reduced LV wall stress which improved ejection fraction.
PEEP increased coronary perfusion pressure by raising diastolic pressure.
PEEP decreased right ventricular afterload which improved cardiac output.
A 55-year-old with cardiac tamponade from malignancy needs an urgent pericardial window. What is the best induction plan?
Administer ketamine and maintain spontaneous ventilation.
Perform spinal anesthesia to avoid myocardial depressants.
Use sevoflurane inhalational induction with nitrous oxide.
Administer propofol and apply high PEEP to improve venous return.
Administer etomidate with a large fentanyl bolus and apply PEEP.
A 47-year-old with severe pulmonary hypertension (mPAP 45) and RV dysfunction presents for laparoscopic appendectomy. What is the best intraoperative hemodynamic target?
Avoid hypoxia, hypercarbia, and acidosis at all times.
Use high PEEP settings to offload the right ventricle.
Administer large fluid boluses to raise CVP above 20 mmHg.
Hyperventilate the patient to a PaCO2 of 25 mmHg.
Use phenylephrine as the first-line agent for any hypotension.
You are asked to start perioperative beta-blocker therapy in a vascular patient with no prior use, two days preoperatively. What is the best approach?
Defer initiation; if indicated, it should begin weeks in advance with careful titration.
Avoid beta-blockers entirely as they are contraindicated in vascular surgery.
Load the patient with metoprolol 200 mg on the morning of surgery.
Start the beta-blocker on the morning of surgery and titrate to a heart rate of 50.
During one-lung ventilation, SpO2 drops from 98% to 88% despite FiO2 1.0. What is the best next step to improve oxygenation consistent with hypoxic pulmonary vasoconstriction physiology?
Apply CPAP to the non-dependent lung or PEEP to the dependent lung.
Increase the sevoflurane concentration from 1.0 to 2.0 MAC.
Hyperventilate the dependent lung to a PaCO2 of 25 mmHg.
Start a nitroprusside infusion to reduce hypoxic pulmonary vasoconstriction.
Switch to a nitrous oxide and oxygen mixture to improve V/Q matching.
A 60-year-old with severe aortic stenosis becomes hypotensive after induction with a MAP of 45 mmHg. What is the best immediate vasopressor?
Titrate phenylephrine to restore vascular resistance.
Titrate dobutamine to improve forward flow.
Titrate isoproterenol to increase heart rate.
Titrate dopamine to augment renal perfusion.
Titrate epinephrine to support blood pressure.
A 72-year-old with moderate mitral stenosis develops atrial fibrillation with rapid ventricular response (HR 150) during surgery. BP is 100/60. What is the best initial therapy?
Institute rate control with a beta-blocker or calcium-channel blocker.
Administer amiodarone for pharmacologic cardioversion.
Perform immediate synchronized cardioversion for hemodynamic stability.
Administer adenosine to diagnose the narrow-complex tachycardia.
Administer procainamide for pharmacologic cardioversion.
A 58-year-old with a drug-eluting stent placed for stable CAD 8 months ago needs an urgent colon resection for cancer. What is the best antiplatelet strategy?
Continue aspirin and stop clopidogrel 5 days preoperatively.
Stop clopidogrel 24 hours preoperatively and continue aspirin.
Continue dual antiplatelet therapy through the surgery.
Stop aspirin 3 days preoperatively and continue clopidogrel.
Stop both aspirin and clopidogrel 7 days preoperatively.
Which ventilator change is most likely to increase right ventricular afterload in a patient with COPD and pulmonary hypertension?
Raising the mean airway pressure or PEEP excessively.
Reducing the I:E ratio from 1:2 to 1:3 to allow more exhalation.
Lowering the tidal volume to a lung-protective level.
Increasing the FiO2 from 0.5 to 1.0 to improve oxygenation.
Adding pressure support during a controlled ventilation mode.
A pulmonary artery catheter is placed in a patient with acute, severe mitral regurgitation. Which tracing change is most characteristic of this condition?
Tall V waves on the pulmonary capillary wedge pressure waveform.
Large cannon A waves on the right atrial pressure waveform.
Development of Kussmaul sign during inspiration.
A blunted Y descent on the right atrial pressure waveform.
Giant A waves on the pulmonary capillary wedge pressure waveform.
A 63-year-old with ischemic cardiomyopathy (EF 25%) requires an open colectomy. Which induction plan best balances hemodynamic stability?
Etomidate-based induction with opioid blunting and a vasopressor ready.
Ketamine-based induction combined with high PEEP settings.
High-dose propofol bolus to ensure rapid loss of consciousness.
Thiopental induction supplemented with nitrous oxide.
High-dose spinal anesthetic with heavy bupivacaine.
During carotid endarterectomy under general anesthesia, sudden ST depression and hypotension occur. What is the best immediate step?
Treat as a myocardial supply–demand mismatch.
Administer esmolol and phenylephrine to target a heart rate of 40.
Administer a large fluid bolus as the sole intervention.
Stop the surgery immediately and extubate the patient.
Start a nitroprusside infusion to manage afterload.
A 50-year-old with HFrEF on sacubitril/valsartan (ARNI) presents for surgery. Which perioperative risk is most typical for this agent compared to an ACE inhibitor?
Refractory hypotension, particularly after induction.
Hypertension refractory to standard treatments.
Isolated hyperkalemia without hemodynamic changes.
Profound bradycardia requiring pharmacologic intervention.
Acute worsening of diastolic function despite volume loading.
A patient on dabigatran with a CrCl of 35 mL/min develops life-threatening bleeding after a regional block. What is the best reversal agent?
Idarucizumab for specific dabigatran reversal.
Andexanet alfa for factor Xa inhibition.
Fresh frozen plasma to restore clotting factors.
Vitamin K to restore vitamin K–dependent factors.
Four-factor prothrombin complex concentrate.
A 54-year-old with severe mitral regurgitation needs a laparoscopic cholecystectomy. Which set of hemodynamic targets is best?
Maintain a slightly higher heart rate, maintain preload, and reduce afterload.
Avoid all volatile anesthetics due to myocardial depression.
Target a very low heart rate to maximize left ventricular filling time.
Target a high afterload to improve coronary perfusion pressure.
Target a low preload and high PEEP to reduce pulmonary congestion.
In cardiac tamponade, which right atrial waveform change is expected?
A blunted Y descent, indicating impaired ventricular filling.
A prominent Y descent, indicating rapid ventricular filling.
Intermittent cannon A waves, indicating AV dissociation.
Kussmaul sign, an inspiratory rise in central venous pressure.
Giant V waves, indicating severe tricuspid regurgitation.
A 70-year-old with a bioprosthetic aortic valve implanted 5 years ago presents for a dental extraction. What is the best approach for endocarditis prophylaxis?
Administer standard endocarditis prophylaxis.
Administer prophylaxis only if the patient has a prior history of endocarditis.
Administer prophylaxis only if the patient has poor dentition.
Administer prophylaxis only if it were within 6 months of implantation.
No endocarditis prophylaxis is indicated for this valve or procedure.
A 64-year-old with diastolic dysfunction (HFpEF) undergoing open hernia repair develops sudden hypotension with a PPV of 8%. What is the best initial therapy?
Administer phenylephrine to restore systemic vascular resistance.
Administer a large fluid bolus to treat the hypovolemia.
Administer esmolol to target a heart rate less than 50 bpm.
Administer dobutamine to improve myocardial contractility.
Administer nitroprusside to reduce left ventricular afterload.
Which intraoperative change is most likely to decrease coronary perfusion pressure?
A propofol-induced systemic vasodilation.
A pharmacologically induced increase in systemic vascular resistance.
A beta-blocker–induced decrease in heart rate.
A reduction in PEEP from 10 to 5 cmH2O.
The development of mild sinus bradycardia.
In a patient with severe pulmonary hypertension undergoing anesthesia, which intervention best supports systemic and right ventricular perfusion during hypotension?
Titrate norepinephrine
Titrate nitroglycerin
Titrate esmolol
Titrate phenylephrine solely to increase SVR
Administer a milrinone bolus first-line
A patient on ticagrelor needs an urgent craniotomy for an epidural hematoma. What is the best strategy to reverse the antiplatelet effect?
Administer bentracimab if available
Administer platelet transfusions alone
Administer intravenous vitamin K
Administer tissue plasminogen activator
Administer desmopressin and tranexamic acid
In severe mitral stenosis, which intraoperative event poses the greatest threat to hemodynamic stability?
Onset of atrial fibrillation with a rapid ventricular response
A mild decrease in systemic vascular resistance
Development of mild permissive hypercarbia
A mild decrease in hemoglobin from blood loss
Development of slight sinus bradycardia
For a patient with a recent PCI who must stop clopidogrel, which short-acting IV agent can bridge P2Y12 inhibition up to the time of incision?
Continuous cangrelor infusion
Eptifibatide started postoperatively
An intravenous aspirin bolus
A continuous heparin infusion
An oral cilostazol load
A 76-year-old with severe aortic stenosis develops a new LBBB and hypotension immediately after aortic cross-clamping. What is the best immediate step?
Request immediate removal of the aortic cross-clamp
Send a troponin and await the result
Increase the volatile anesthetic to 2 MAC
Place an arterial line and treat the hypotension
Administer amiodarone for the conduction abnormality
Dynamic LVOT obstruction is suspected after aggressive diuresis; TEE shows systolic anterior motion (SAM). What is the best acute therapy?
Administer phenylephrine and a fluid bolus
Administer nitroglycerin to reduce preload and afterload
Administer dobutamine to increase contractility
Administer milrinone to improve diastolic relaxation
Increase PEEP to augment LV afterload
Under general anesthesia, a 67-year-old with aortic regurgitation becomes profoundly bradycardic (HR 40) but normotensive. What is the main hemodynamic risk of this rhythm?
Increased diastolic time allowing more regurgitation
Development of coronary steal
Development of respiratory alkalosis
Development of hyperkalemia from shifts
Acute RV ischemia from pressure overload
A 55-year-old with EF 30% needs major abdominal surgery. Which property of modern volatile agents is most favorable in this patient?
Titrated afterload reduction but hypotension must be avoided
Sevoflurane is contraindicated in all LV dysfunction
Halothane preferred for baroreflex preservation
Nitrous oxide ideal due to reduced PVR
Desflurane provides profound sympathetic blunting at all doses
A patient with a CRT-D needs a TURP with bipolar cautery below the umbilicus. What is the best device management plan?
No routine reprogramming or magnet use is required
Turn off all pacing functions preoperatively
Disable all tachyarrhythmia therapies
Place a magnet to ensure asynchronous pacing
Replace the device with a temporary pacemaker
During prone spine surgery with controlled ventilation, PPV is 18%, Vt 6 mL/kg, PEEP 5, MAP 70, and CVP 10 mmHg. What is the best interpretation?
Patient is likely fluid responsive if other criteria are met
Patient is not fluid responsive due to prone position
High PPV suggests pneumothorax
Findings indicate acute RV failure
High PPV indicates need for vasodilator therapy
For a septic patient with Hb 7 g/dL, SaO2 100%, and cardiac output 3 L/min, which intervention will most significantly increase DO2?
Packed red blood cell transfusion
Raise FiO2 from 0.6 to 1.0
Decrease PEEP from 10 to 5 cmH2O
Start nitroglycerin to reduce afterload
Increase minute ventilation to induce hypocapnia
A patient with a mechanical mitral valve on warfarin has INR 2.8 and needs urgent laparotomy. What is the best immediate reversal strategy to allow surgery?
Administer 4-factor PCC and intravenous vitamin K
Administer IV vitamin K only and wait 6 hours
Administer FFP as the sole reversal agent
Administer protamine based on the warfarin dose
Administer idarucizumab for rapid nonspecific reversal
TEE during hypotension shows a small LV cavity, hyperdynamic walls, and no regional wall motion abnormalities. What is the most likely cause and treatment?
Relative hypovolemia; give fluids and vasopressors
Cardiac tamponade; increase PEEP
Pulmonary embolism; give thrombolysis
Myocardial infarction; administer nitroglycerin
RV infarct; administer nitroglycerin and fluids
A patient with moderate mitral regurgitation is in the beach-chair position for shoulder surgery. MAP measured at the arm is 65 mmHg. The brain is 30 cm above the transducer. What is the approximate cerebral perfusion pressure? (Assume hydrostatic gradient of ~0.77 mmHg/cm)
42 mmHg
35 mmHg
58 mmHg
65 mmHg
75 mmHg
After spinal anesthesia, a patient with severe aortic stenosis becomes hypotensive and tachycardic. What is the best immediate step?
Administer phenylephrine and address the tachycardia
Administer ephedrine as the sole vasopressor
Administer atropine and a nitroglycerin infusion
Place in Trendelenburg and give fluids only
Administer high-flow oxygen via non-rebreather
A patient with Brugada pattern is undergoing anesthesia. Which drug exposure is most concerning for provoking malignant arrhythmias in this syndrome?
A high-dose propofol infusion.
A high-dose phenylephrine infusion.
A high-dose rocuronium bolus.
A high-dose fentanyl bolus.
A high-dose etomidate bolus.
For a patient with severe pulmonary hypertension on chronic sildenafil and inhaled treprostinil, which agent is preferred to treat systemic hypotension intraoperatively?
A continuous norepinephrine infusion.
A continuous phenylephrine infusion.
A high-dose vasopressin infusion as first-line.
A continuous nitroglycerin infusion.
A continuous esmolol infusion.
A patient with hypertrophic obstructive cardiomyopathy (HOCM) on a beta-blocker remains hypotensive (MAP 55) after induction despite phenylephrine and volume. What is the next best step?
Add a vasopressin infusion to augment SVR.
Start a nitroprusside infusion to reduce afterload.
Increase the sevoflurane concentration to deepen anesthesia.
Switch from phenylephrine to ephedrine boluses.
Start a dobutamine infusion to support contractility.
During transesophageal echocardiography (TEE), you suspect an acute pulmonary embolism. Which immediate finding is most supportive of this diagnosis?
A dilated right ventricle with septal flattening and McConnell sign.
A hyperdynamic left ventricle with a low gradient.
The development of new, severe mitral stenosis.
A small, hypertrophied right ventricle.
The new appearance of a large pericardial effusion.
A 65-year-old with CKD and an NSTEMI 1 month ago (managed medically) needs an urgent colectomy for a bleeding cancer. What is the best perioperative troponin strategy?
Obtain baseline and postoperative troponins for surveillance.
Do not order any troponins in the perioperative period.
Order troponins only if the patient develops symptoms.
Order an echocardiogram instead of troponins.
Order daily ECGs instead of troponins.
During laparoscopic surgery, a patient with a fixed-rate VVI pacemaker develops profound bradycardia with insufflation. A magnet is placed, but the heart rate remains low. What is the most likely reason?
Not all pacemakers convert to an asynchronous mode with a magnet.
The magnet is supposed to increase the heart rate, indicating a malfunction.
The magnet has disabled all pacing functions, causing asystole.
The magnet has incorrectly converted the pacemaker to a DDD mode.
The magnet has inadvertently turned on ICD therapies.
A 69-year-old with stable CAD and prior CABG needs an urgent hemicolectomy. Intraoperatively, ST depressions and tachycardia occur with MAP 62. Which intervention best improves the myocardial supply-demand balance?
Titrate esmolol to reduce heart rate while supporting MAP with norepinephrine.
Administer nitroprusside to reduce left ventricular afterload.
Start a dobutamine infusion to improve myocardial contractility.
Increase the sevoflurane concentration to 1.5 MAC.
Administer a large crystalloid bolus to improve preload.
A 58-year-old on a high-dose long-acting beta-blocker for CAD is NPO since midnight. On induction, he becomes bradycardic (HR 38) and hypotensive (MAP 45). What is the best initial drug?
Administer ephedrine 10 mg for combined alpha and beta effects.
Administer nitroglycerin 100 μg to reduce preload and afterload.
Administer atropine 0.4 mg to block vagal input.
Administer lidocaine 100 mg to treat any ventricular arrhythmia.
Administer esmolol 30 mg to treat reflex tachycardia.
A 76-year-old with low-flow, low-gradient AS (AVA 0.8 cm², EF 30%) is for urgent laparotomy. A dobutamine stress echo shows the mean gradient rising to 50 mmHg with an unchanged AVA. What is the most relevant interpretation for anesthetic risk?
This is true severe AS with contractile reserve; treat as severe fixed obstruction.
The data is inconsistent and the surgery must be canceled.
This represents non-severe AS with a dynamic obstructive component.
This represents pseudo-severe AS; the risk is similar to moderate AS.
The patient should be managed as if they have HOCM.
You plan an arterial line for a carotid endarterectomy under general anesthesia. Shortly after cross-clamp, the EEG shows ischemic changes. The surgeon requests a higher pressure. What is the most appropriate immediate target?
Raise the mean arterial pressure more than 20% above the patient's baseline.
Lower the mean arterial pressure to reduce cerebral edema formation.
Maintain the arm mean arterial pressure between 60–65 mmHg.
Switch to a nitroprusside infusion to improve collateral flow.
Keep the mean arterial pressure unchanged and administer mannitol.
A 63-year-old with moderate mitral stenosis and pulmonary hypertension needs an emergent open cholecystectomy. Which ventilator strategy best avoids acute decompensation?
Use low-moderate PEEP and avoid hypercarbia to allow for diastolic filling.
Increase the I:E ratio to 1:1 to improve mean airway pressure.
Use high PEEP settings to reduce right ventricular afterload.
Maximize the tidal volume to reduce the dead space fraction.
Hyperventilate the patient to a PaCO2 of 25 mmHg to reduce PVR.
A 72-year-old with EF 20% and a CRT-P presents for femur fracture fixation. During reaming, BP falls to 70/40, ETCO2 drops, and TEE reveals a dilated RV with a preserved LV. Which first action best addresses the likely pathophysiology?
Administer 100% oxygen and treat hypotension with norepinephrine.
Administer esmolol to slow the heart rate and improve RV filling.
Administer furosemide to treat the acute RV volume overload.
Increase the PEEP to 12 cmH2O to splint the right ventricle.
Start a nitroglycerin infusion to reduce RV preload and afterload.
A 61-year-old on prasugrel for a DES placed 9 months ago (stable angina) needs a semi-urgent colectomy in 4 days. What is the best antiplatelet strategy?
Continue aspirin; stop prasugrel now to allow for a 7-day washout.
Continue both antiplatelet agents up to the day of surgery.
Stop aspirin but continue prasugrel up to the day of surgery.
Stop both antiplatelet agents 5 days before the procedure.
Bridge the patient with an intravenous heparin infusion.
Intraoperative torsades de pointes occurs in a patient with long-QT syndrome after ondansetron. The blood pressure is 70/40, and the patient is still perfusing. What is the best immediate treatment?
Administer magnesium sulfate 2 g IV immediately.
Administer lidocaine 100 mg as a first-line antiarrhythmic.
Start an esmolol infusion to suppress the arrhythmia.
Administer amiodarone 150 mg over 10 minutes.
Administer adenosine 6 mg for rapid conversion.
A patient with severe aortic regurgitation under general anesthesia becomes hypotensive (MAP 55) and bradycardic (HR 45) after a large remifentanil bolus. Which vasopressor or inotrope is best now?
Administer ephedrine or low-dose epinephrine to increase heart rate.
Give phenylephrine to raise diastolic pressure.
Start vasopressin to increase SVR without affecting HR.
Start norepinephrine to increase SVR and reflexively lower HR.
Administer esmolol to reduce vagal tone then reassess.
A 74-year-old with HFpEF and concentric LVH becomes acutely hypotensive after induction. The stroke-volume variation is 7%. Which action most likely corrects the underlying cause?
Administer a small phenylephrine bolus, then give cautious fluids.
Start a nitroprusside infusion to reduce afterload.
Administer a 1 L fluid bolus to treat the low SVV.
Start a dobutamine infusion to improve contractility.
Increase PEEP to 10 cmH2O to improve V/Q matching.
A 66-year-old with a mechanical mitral valve (bileaflet) on warfarin (goal INR 3.0) needs an elective open hysterectomy. She has a prior history of stroke. What is the best bridging plan?
Stop warfarin 5 days prior and bridge with therapeutic LMWH or UFH.
Continue warfarin and have fresh frozen plasma available.
Stop warfarin 2 days prior to the procedure only.
Stop warfarin 5 days prior and do not provide bridging.
Switch the patient to a DOAC 48 hours before surgery.
Post-carotid endarterectomy, a normocapnic patient becomes acutely hypertensive (MAP 120) with a severe headache and focal seizures. What is the most likely diagnosis requiring urgent control?
Cerebral hyperperfusion syndrome from loss of autoregulation.
A transient ischemic attack resulting from hypotension.
Acute carotid artery thrombosis at the surgical site.
An intracranial hemorrhage from anticoagulation reversal.
Symptomatic hypoglycemia from perioperative stress.
During an open AAA repair, a supraceliac cross-clamp is applied. Which change is most expected and must be managed?
An acute increase in afterload and left ventricular wall stress.
A decrease in left ventricular end-diastolic pressure.
A significant fall in systemic afterload and blood pressure.
A decrease in coronary perfusion pressure due to high diastolic pressure.
An immediate compensatory increase in renal blood flow.
Clamp release after an AAA repair causes profound hypotension and acidosis. What is the best pre-emptive strategy to attenuate this response?
Ensure volume loading, reduce anesthetic depth, and have vasopressors ready.
Administer a nitroprusside infusion just before release.
Maintain hyperventilation throughout the clamp period.
Increase the PEEP settings just before clamp release.
Administer furosemide 10 minutes before clamp release.
A 68-year-old with a CRT-D is paced biventricularly 98% of the time. You plan a shoulder arthroplasty with monopolar cautery. What is the most reliable strategy to avoid inhibition of pacing?
Reprogram to an asynchronous pacing mode and disable ICD therapies.
Turn off the device using a magnet during the case.
Use short-burst cautery and rely on the intrinsic rhythm.
Use bipolar cautery as the sole precaution.
Place a magnet over the device for the entire duration of the case.
A 73-year-old with critical aortic stenosis arrives hypotensive after receiving spinal anesthesia at an outside center. Which two principles guide immediate therapy?
Restore SVR with an alpha-agonist and maintain sinus rhythm.
Reduce afterload with clevidipine and provide fluids.
Promote tachycardia and vasodilation with ephedrine.
Apply high PEEP and administer nitroglycerin.
Administer a beta-agonist inotrope and reduce preload.
During laparoscopic colectomy, suspected PE leads to rising PA pressures, hypotension, and a sudden ETCO2 drop. TEE shows RV free-wall akinesis with apical sparing. What is the best immediate additional therapy?
Start an inhaled pulmonary vasodilator and support MAP with norepinephrine.
Start a nitroglycerin infusion to reduce RV preload and afterload.
Start an epinephrine infusion for combined inotropy and vasopressor support.
Increase PEEP to 15 cmH2O to splint the right ventricle.
Start an esmolol infusion to control myocardial oxygen demand.
For a patient with a pheochromocytoma optimized with doxazosin, which intraoperative vasopressor choice best treats hypotension after tumor vein ligation?
A continuous norepinephrine infusion.
A continuous nitroglycerin infusion.
A continuous esmolol infusion.
A continuous nicardipine infusion.
A continuous phenylephrine infusion.
A 70-year-old with severe mitral regurgitation and chronic, rate-controlled atrial fibrillation presents for noncardiac surgery. Which plan best maintains forward flow?
Avoid bradycardia, maintain preload, and reduce afterload.
Maintain a heart rate less than 50 bpm to increase filling time.
Use deep volatile anesthesia to suppress HPV.
Use pure alpha-agonists for any hypotensive episodes.
Use high PEEP settings to reduce systemic preload.
An 82-year-old with constrictive pericarditis is scheduled for pericardiectomy. Which waveform or bedside sign is typical of this condition and helps distinguish it from tamponade?
Kussmaul sign with a prominent Y descent.
Significant pulsus paradoxus greater than 10 mmHg.
Equalization of diastolic pressures with a blunted Y descent.
A water-hammer pulse on arterial line tracing.
Electrical alternans on the electrocardiogram.
A 55-year-old with EF 25% undergoing colectomy exhibits hypotension after induction. The PAOP is 8 mmHg, and TEE shows a small LV cavity with a dynamic mid-cavity gradient. What is the best pharmacologic step?
Administer phenylephrine and a small volume bolus.
Start a nitroglycerin infusion to reduce afterload.
Start a dobutamine infusion to augment contractility.
Start a milrinone infusion to improve lusitropy.
Administer an esmolol bolus followed by nitroprusside.
A patient with a bileaflet mechanical aortic valve and no other risk factors is scheduled for an elective herniorrhaphy. What is the best anticoagulation approach?
Hold warfarin 5 days prior and do not bridge with heparin.
Continue warfarin through the perioperative period.
Switch to a DOAC 72 hours preoperatively.
Hold warfarin 2 days prior and check the INR morning of.
Bridge with full-dose heparin regardless of valve position.
A 64-year-old with HFrEF on sacubitril/valsartan, carvedilol, and spironolactone presents for major abdominal surgery. Which preop medication plan best reduces hemodynamic instability?
Continue the beta-blocker; consider holding the ARNI morning-of.
Continue all three medications on the morning of surgery.
Stop spironolactone only to avoid intraoperative hyperkalemia.
Hold the beta-blocker to avoid intraoperative bradycardia.
A patient with Wolff-Parkinson-White (WPW) undergoing general anesthesia develops a narrow-complex SVT at 190 bpm with blood pressure 70/40 and poor perfusion. What is the best immediate step?
Perform immediate synchronized cardioversion.
Start an esmolol infusion for rate control.
Administer procainamide 10 mg/kg IV.
Administer diltiazem 20 mg IV bolus.
Administer adenosine 6 mg IV push.
Regarding perioperative statins in a vascular surgery patient with no prior use, which statement is most evidence-based?
Initiate statins days to weeks preoperatively if time allows.
Administer statins only if LDL >190 mg/dL.
Start a high-dose statin on the morning of surgery for benefit.
There is no proven role for statins in the perioperative period.
Stop statins in chronic users to avoid rhabdomyolysis.
A 71-year-old with moderate aortic regurgitation and CKD develops severe hypotension during sepsis. Which continuous vasoactive profile is most favorable?
Norepinephrine infusion with epinephrine if needed.
Vasopressin infusion as the sole agent.
Dopamine infusion for renal-dose effects.
High-dose phenylephrine infusion.
Esmolol infusion to control heart rate.
After induction for laparoscopic nephrectomy in pulmonary hypertension, PETCO2 drops and hypoxemia develops during insufflation. PAP rises from 35 to 65 mmHg. Which ventilatory change best reduces PVR?
Increase minute ventilation to avoid hypercarbia and keep PEEP modest.
Use high tidal volumes (10–12 mL/kg).
Switch to nitrous oxide and oxygen mixture.
Increase PEEP to 15 cmH2O to splint the right ventricle.
Prolong inspiratory time to an I:E of 1:1.
A 62-year-old with Brugada syndrome requires general anesthesia for bowel resection. Which anesthetic plan best minimizes malignant arrhythmia risk?
Use a balanced anesthetic and maintain normothermia.
Maintain anesthesia with a continuous ketamine infusion.
Place a high-dose bupivacaine epidural for anesthesia.
Use sevoflurane at 2 MAC combined with hyperventilation.
Maintain anesthesia with a long propofol infusion.
A 66-year-old with left main disease and poor functional capacity needs urgent colectomy for perforation. Which monitoring choice most improves the ability to manage ischemia and hemodynamics?
Arterial line and transesophageal echocardiography.
Standard ASA monitors only.
Pulmonary artery catheter as the sole advanced monitor.
Central venous catheter and an arterial line.
Precordial ST segment leads on the ECG.
In a high-risk vascular patient unable to exercise, which noninvasive test best identifies balanced three-vessel ischemia?
Vasodilator nuclear perfusion imaging.
Dobutamine stress echocardiography.
Coronary artery calcium scoring.
Six-minute walk test.
Resting transthoracic echocardiography.
A patient with severe mitral regurgitation (flail posterior leaflet) and normal coronaries is scheduled for noncardiac surgery. Which induction choice best preserves forward flow?
Etomidate or small-dose propofol with an opioid; prefer vasodilators.
Spinal anesthesia with high-dose heavy bupivacaine.
Ketamine followed by esmolol bolus to control heart rate.
Large propofol bolus followed by phenylephrine as needed.
High-dose remifentanil bolus followed by phenylephrine.
A 48-year-old with long-standing hypertension shows an LV strain pattern on ECG and concentric LVH on echo. Which intraoperative blood pressure strategy best reduces myocardial events?
Maintain BP within 10–20% of baseline.
Lower diastolic pressure aggressively to improve LV filling.
Target MAP of 55–60 mmHg to reduce bleeding.
Keep systolic BP <100 mmHg throughout.
Use permissive hypotension to reduce oxygen demand.
A patient with permanent atrial fibrillation on apixaban presents for urgent hip fixation 36 hours after the last dose. CrCl is 35 mL/min. You plan neuraxial anesthesia. What is the most appropriate action?
Avoid neuraxial techniques; consider general anesthesia or a peripheral block.
Proceed with an epidural using a test dose only.
Administer PCC then proceed with neuraxial block.
Administer vitamin K then proceed with neuraxial block.
Proceed with a single-shot spinal anesthetic now.
During thoracotomy, TEE reveals acute severe tricuspid regurgitation with a dilated RV and septal shift. Which step best improves RV output?
Optimize preload, reduce PEEP, and support MAP with norepinephrine.
Increase PEEP to 15 cmH2O to reduce venous return.
Decrease FiO2 to 0.5 to augment HPV.
Administer esmolol to slow heart rate and improve filling.
Start nitroprusside to reduce PVR.
A 70-year-old with a bioprosthetic AVR placed 3 months ago is on aspirin alone and needs noncardiac surgery. What is the best antiplatelet plan?
Continue aspirin through the perioperative period.
Stop aspirin 7 days prior to the procedure.
Bridge with a continuous heparin infusion.
Stop aspirin 24 hours prior to the procedure.
Add clopidogrel temporarily for enhanced protection.
In severe aortic stenosis, which arrhythmia is most poorly tolerated and should be aggressively prevented or treated?
New-onset atrial fibrillation with loss of atrial contribution.
Junctional rhythm with a heart rate of 70 bpm.
Sinus bradycardia at 55 bpm.
Sinus tachycardia at 110 bpm.
First-degree AV block with a stable PR interval.
A 60-year-old with HFrEF and severe CAD has persistent hypotension despite adequate volume and norepinephrine. Lactate is rising. TEE shows global depression, no obstruction, and a full IVC. What is the best next pharmacologic approach?
Add an inodilator such as dobutamine or milrinone while maintaining MAP.
Increase volatile anesthetic depth to reduce demand.
Add a phenylephrine infusion to further increase SVR.
Switch to high-dose epinephrine as the sole agent.
Administer nitroglycerin to reduce preload and afterload.
A patient with Mobitz II block needs an urgent laparotomy. Which pre-induction step best reduces the risk of peri-induction cardiac arrest?
Place temporary pacing capability (transvenous or transcutaneous) before induction.
Administer atropine pre-induction to prevent bradycardia.
Give a prophylactic epinephrine infusion during induction.
Proceed with induction using ketamine to avoid hypotension.
Use spinal anesthesia instead of general anesthesia.
TEE during unexplained hypotension shows a large pericardial effusion with diastolic RV collapse and low ETCO2. Which maneuver is most harmful before drainage can be performed?
Initiating positive-pressure ventilation with high PEEP
Administering a phenylephrine bolus
Maintaining spontaneous ventilation
Administering a small fluid bolus
Administering ketamine for induction
A 68-year-old with resistant hypertension and CKD becomes severely hypertensive (MAP 125) on emergence, without pain. Which titratable IV agent offers predictable BP control and favorable organ perfusion?
Nicardipine infusion with careful titration
Esmolol infusion as the sole therapy
Hydralazine boluses for sustained control
Nitroprusside infusion as first-line therapy
Large boluses of labetalol for rapid control
A 72-year-old develops myocardial injury after noncardiac surgery (MINS) with a troponin rise but no ischemic symptoms. Which action best improves outcomes?
Optimize hemodynamics and initiate or continue guideline-directed medical therapy
Start routine thrombolysis for a suspected silent MI
Ignore the troponin rise as the patient is asymptomatic
Make the patient NPO and await further developments
Order an immediate cardiac catheterization
A 65-year-old with severe pulmonary hypertension on a continuous IV epoprostenol infusion via dedicated lines undergoes surgery. The pump fails intraoperatively. What is the first step?
Resume the epoprostenol infusion immediately and support MAP with norepinephrine
Increase PEEP to 15 cmH2O to splint the right ventricle
Give a nitroglycerin bolus to manage rebound hypertension
Start vasopressin as the sole replacement therapy
Clamp the line to prevent an air embolism and restart the pump
A patient with moderate aortic stenosis and CAD takes a chronic beta-blocker before major abdominal surgery. What is the best perioperative plan for the beta-blocker?
Continue the beta-blocker perioperatively to avoid withdrawal
Hold the beta-blocker to avoid intraoperative bradycardia
Replace the beta-blocker with a calcium channel blocker
Convert to a short-acting beta-blocker and stop it after induction
Give a high loading dose on the morning of surgery
A 59-year-old with optimized Takotsubo cardiomyopathy (EF 30%) after a recent stressor needs urgent laparotomy. Which intraoperative pressor/inotrope profile is favored?
Norepinephrine for MAP support, avoiding high beta-1 stimulation
Continuous dopamine infusion for renal and cardiac support
High-dose dobutamine infusion (10 µg/kg/min) as first-line
High-dose epinephrine infusion for alpha and beta support
Continuous isoproterenol infusion to increase heart rate
A 70-year-old with RBBB and prior anterior MI develops a new bifascicular block with hypotension and bradycardia during hip arthroplasty. What is the best immediate management?
Begin transcutaneous pacing and prepare for transvenous pacing
Administer atropine as the sole therapy
Administer adenosine to diagnose the block
Continue the surgery and observe closely
Administer esmolol to slow the ventricular rate
For a patient with severe mitral stenosis undergoing noncardiac surgery, which fluid and vasoactive plan is best?
Maintain preload, avoid tachycardia, and treat hypotension with phenylephrine
Use high PEEP settings to reduce pulmonary edema
Administer aggressive fluids and vasodilators
Use ephedrine as the first-line agent for any hypotension
Lower systemic vascular resistance with a nitroprusside infusion
A 63-year-old with ischemic mitral regurgitation undergoes laparoscopy. Insufflation raises SVR and worsens hypotension. Which intervention best improves forward flow?
Reduce pneumoperitoneum pressure and add nitroglycerin while supporting MAP
Administer phenylephrine boluses to support the SVR
Give an esmolol bolus to control heart rate
Increase the PEEP to 12 cmH2O to reduce preload
In large pericardial effusion with hemodynamic compromise, which induction agent-choice combination is least likely to precipitate collapse prior to pericardial drainage?
Maintain spontaneous ventilation and avoid high PEEP
Rapid sequence induction with high-dose propofol
Deep inhalational induction with high volatile concentration
Bag-mask ventilation with high PEEP before intubation
Immediate paralysis and controlled ventilation
During emergence, a patient with hypertrophic obstructive cardiomyopathy (HOCM) becomes hypotensive and tachycardic. Which immediate management best addresses the pathophysiology?
Give phenylephrine and beta-block to reduce obstruction and improve preload
Administer nitroprusside to reduce afterload
Increase inotropes such as dobutamine
Hyperventilate to reduce CO2 and increase HR
Use diuretics to reduce preload
In severe pulmonary hypertension when prostacyclin infusion is interrupted, which ventilatory strategy should be avoided while resuscitating?
Avoid high PEEP and maintain normocapnia to support RV preload and afterload
Increase PEEP to 15–20 cmH2O to reduce RV volume overload
Hyperventilate to target respiratory alkalosis and severe hypocapnia
Use one-lung ventilation to reduce shunt
Switch to high-frequency ventilation immediately
