Essentials of Cardiopulmonary

Physical Therapy 4th Edition Hillegass

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Chapter 08: Cardiovascular Diagnostic Tests and Procedures
Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition

MULTIPLE CHOICE

1. Sensitivity of a diagnostic test is one method of determining the accuracy of a test. Which of
the following statements BEST defines sensitivity?
a. The proportion of those individuals without the disease with a true negative test
b. The proportion of those individuals with the disease who have a true positive test
c. The proportion of individuals who had a positive test and actually have the disease
d. The proportion of individuals who had a negative test and truly do not have the
disease
ANS: B
Sensitivity is defined as the proportion of those individuals with the disease who have a true
positive test.

PTS: 1

2. Specificity of a diagnostic test is one method of determining the accuracy of a test. Which of
the following statements BEST defines specificity?
a. The proportion of those individuals without the disease with a true negative test
b. The proportion of those individuals with the disease who have a true positive test
c. The proportion of individuals who had a positive test and actually have the disease
d. The proportion of individuals who had a negative test and truly do not have the
disease
ANS: A
Specificity is defined as the proportion of those individuals without the disease with a true
negative test.

PTS: 1

3. Which of the following biomarkers is MOST conclusive for myocardial injury?

a. CK-MB
b. CK-MM
c. CK-BB
d. All of the above
ANS: A
The CK-MB fraction is most conclusive for myocardial injury. CK-MM is conclusive for
skeletal muscle damage and BB for brain tissue injury.

PTS: 1

4. Which of the following biochemical markers is considered to be the gold standard indicator of
myocardial damage because it is more conclusive to cardiac tissue?
a. Creatine phosphokinase (CK-MB)
b. Lactic dehydrogenase (LDH isoenzyme)
c. Aspartate aminotransferase (AST)
 d. Troponin (cTnl, cTnT)
ANS: D
Blood levels of the troponins have been assessed to determine myocardial damage and are
now considered the gold standard. Elevated levels of troponin occur earlier and may last for
up to 5 to 7 days in plasma.

PTS: 1

5. Which of the following statements is FALSE regarding elevated troponin levels?

a. Elevated troponin levels assist the clinician in identifying the specific cause.
b. The higher the troponin levels, the greater the damage to cardiac tissue.
c. Critically ill patients with sepsis may have increased troponin levels.
d. Troponin levels remain elevated for 10 days after injury.
ANS: A
Answer “A” is false. Elevated troponin levels are not specific to the cause of the injury.
Several conditions that may cause damage to cardiac tissue will elevate troponin levels.

PTS: 1

6. Which of the following components of complete blood cell count would be indicative of
impeded blood flow secondary to increase blood viscosity?
a. Low hemoglobin levels
b. Elevated hematocrit levels
c. Small RBCs
d. Elevated WBCs
ANS: B
Elevated hematocrit levels suggest that the flow of blood to the tissues may be impeded
because of an increase in the viscosity of the blood. Elevated hematocrit levels are often seen
in individuals with chronic obstructive pulmonary disease (response to low PO2).

PTS: 1

7. An elevated international normalized ratio (INR) should alert the therapist to consider which
of the following?
a. Avoid having the patient walk a long distance due to low endurance.
b. Avoid out-of-bed physical activity due to low oxygen-carrying capacity.
c. Be cautious about moving the patient from supine to stand quickly.
d. Be cautious about bumping extremities with all movements.
ANS: D
An elevated INR indicates an increased time to form a clot; therefore, the chance of bleeding
when bruised or cut is increased and caution should be taken to avoid bumping the extremities
during all movements.

PTS: 1

8. Which of the following laboratory values is indicative of the possible occurrence of

life-threatening arrhythmias?
a. Low levels of CO2
 b. Low levels of potassium
c. High levels of sodium
d. High creatinine levels
ANS: B
Dangerously low levels of potassium (below 3.5 mEq/L) can cause serious life-threatening
arrhythmias.

PTS: 1

9. Which of the following laboratory values measure how well a patient with diabetes controls
serum glucose over the most recent 90 days?
a. Serum glucose
b. Hemoglobin A1c
c. Albumin
d. BNP
ANS: B
Testing hemoglobin A1c measures a diabetic’s insulin control over the past 90 days, which is
the life of the red blood cells that carry the hemoglobin.

PTS: 1

10. Which of the following reasons are considered indications for a Holter monitor?
a. Identifying symptoms caused by arrhythmias
b. Describing the arrhythmias noted with activity
c. Evaluating antiarrhythmic therapy or pacemaker functioning
d. All of the above
ANS: D
Identifying symptoms possibly caused by arrhythmias, describing the arrhythmias noted with
activity, and evaluating antiarrhythmic therapy or pacemaker functioning are all indications
for Holter monitor use.

PTS: 1

11. The physical therapist during an evaluation learns that his patient has recently worn a Holter
monitor to investigate a report of shortness of breath during activity. Which of the following
actions is MOST appropriate for the physical therapist to take next?
a. Continue with the evaluation and proceed with an exercise stress test to determine
if shortness of breath occurs.
b. Hold any activity component of the evaluation and contact the physician and
request a copy of the Holter monitoring report.
c. Stop the evaluation and refer the patient back to the physician for clearance to
participate in physical therapy.
d. Call the physician to request a copy of the Holter monitoring report and continue
treating the patient until the report is received stating otherwise.
ANS: B
 It is the responsibility of the physical therapist working with the patient who is wearing or has
worn a Holter monitor to obtain the interpretation of the results of the monitor to determine if
modifications are needed in the patient’s activity. The physical therapist should practice
autonomy by maintaining the care of the patient, but delaying physical activity until additional
diagnostic information is received.

PTS: 1

12. Which of the following statements conveys the LEAST important rationale for using
transesophageal echocardiography (TEE) instead of a standard echocardiogram?
a. The transesophageal echocardiography is invasive.
b. Confounding factors such as pulmonary disease, obesity, or chest deformity may
exist.
c. Useful in detection of those at risk for embolic stroke.
d. Gauge the severity of certain valve problems.
ANS: A
TEE is superior to the image quality of a standard echocardiogram due to its location in the
esophagus directly behind the heart. The invasiveness of the procedure is the only
disadvantage for the patient.

PTS: 1

13. Which of the following imaging modalities is considered the gold standard for blood flow
measurement and metabolic assessment of the heart but requires high cost and specially
trained personnel?
a. Computed tomography
b. Multigated acquisition imaging
c. Magnetic resonance imaging
d. Positron emission tomography (PET)
ANS: D
PET is considered to be the gold standard for blood flow measurement and metabolic
assessment of the heart, but it requires specialized technological equipment and highly trained
personnel and therefore is extremely expensive and not available at many hospitals.

PTS: 1

14. An imaging modality that detects calcium in the coronary arteries and is a noninvasive
method to detect and quantify coronary atherosclerosis BEST describes which of the
following?
a. Computed tomography
b. Single-photon emission computed tomography
c. Electron beam computed tomography
d. Magnetic resonance imaging
ANS: C
The electron beam computed tomography is used to detect calcium in the coronary arteries
and is a noninvasive method to detect and quantify coronary atherosclerosis. Calcium in the
coronary arteries may be an early sign of coronary artery disease.
 PTS: 1

15. Which of the following imaging modalities is often the diagnostic tool of choice over the PET
imaging for measuring myocardial perfusion?
a. Computed tomography
b. Single-photon emission computed tomography (SPECT)
c. Electron beam compute tomography
d. Magnetic resonance imaging
ANS: B
SPECT imaging, although less accurate than PET imaging, is more often the diagnostic tool
of choice because of the availability of these gated imaging machines and the ease of
performance.

PTS: 1

16. An exercise test that is terminated on achievement of a predetermined end point (less than
maximal) is termed which of the following?
a. Low-level testing
b. Maximal stress test
c. Submaximal test
d. Pulse recovery test
ANS: C
Submaximal tests are terminated on achievement of a predetermined end point (unless
symptoms otherwise limit completion of the test). The predetermined end point may be either
the achievement of a certain percentage of the patient’s predicted maximal heart rate or the
attainment of a certain workload.

PTS: 1

17. Which of the following tests is MOST useful for identifying the high-risk patient?
a. Low-level testing
b. Maximal stress test
c. Submaximal test
d. Pulse recovery test
ANS: A
Low-level exercise testing is usually performed when patients have experienced an MI
recently or have undergone coronary artery bypass graft surgery. Low-level exercise testing
may be useful in predicting the subsequent course of an MI or bypass surgery as well as for
identifying the high-risk patient.

PTS: 1

18. Which of the following factors from the results of a low-level exercise test was determined to
be the MOST significant factor for identifying high-risk patients?
a. Exercise-induced arrhythmias
b. Exercise-induced angina
c. Inappropriate blood pressure response
d. Exercise-induced ST-segment depression of 2.0 mm
 ANS: D
An exercise-induced ST-segment depression of 2.0 mm or greater on a low-level exercise test
has been identified as the single most valuable indicator of prognosis after MI according to the
regression analysis by Davidson and DeBusk.

PTS: 1

19. Which of the following factors enhance the safety of exercise testing?
a. Knowledge of when to exclude a patient
b. Knowledge of when to terminate an exercise test
c. Knowledge and skills to react to an abnormal response
d. All of the above
ANS: D
All of the factors listed enhance the safety of exercise testing. Additionally, having the
necessary equipment available for emergencies and having the patient sign an informed
consent are important factors.

PTS: 1

20. Which of the following variables identified in a maximal exercise test would BEST reflect
low risk for developing coronary artery disease (CAD)?
a. Exercise time of more than 6 minutes
b. The presence of angina
c. Achieved maximal heart rate considerably below predicted
d. Maximal systolic blood pressure <130 mm Hg
ANS: A
Variables associated with a low risk for CAD, including an exercise time of >6 minutes,
maximum heart rate of more than 150 beats/min, and an ST recovery time of <1 minute, were
identified in women. Variables that suggested a greater risk for subsequent cardiac event
included ST-segment depression, bradycardiac heart rate response, presence of angina, and
maximal systolic blood pressure attained.

PTS: 1

21. Which of the following variables would contribute to a less valid maximal exercise test?
a. Consistent adherence to a protocol
b. Competent examiners with previously demonstrated proficiency
c. Provision of encouragement to the patient
d. Instructing the patient to use a handrail only when ready to terminate the test
ANS: C
The value of diagnostic stress testing is tempered by the amount of variability among
examiners conducting the test. Problems with testing include amount of encouragement given
to a patient, a lack of strict adherence to protocols, use of handrail support, and interpretation
of ST-segment deviations and symptoms.

PTS: 1

22. Which of the following pharmacological cardiac testing procedures is BEST for confirming
coronary artery spasm?
 a. Administration of adenosine
b. Administration of dobutamine
c. Administration of regadenoson
d. Administration of ergonovine
ANS: D
Ergonovine stimulation is used when coronary artery spasm is suspected, particularly in a
patient with documented ECG changes during symptoms or with documented ischemic
episodes and a normal coronary angiography study. The test has a high degree of sensitivity
and specificity for coronary vasospasm.

PTS: 1

23. The results of a cardiac catheterization indicate the left ventricle is normal in size with
anteroapical hypokinesis. Which of the following statements BEST defines hypokinesis of a
cardiac region?
a. The anteroapical region is demonstrating low electrical activity.
b. The anteroapical region is demonstrating sluggish movement.
c. The anteroapical region is demonstrating muscle fatigue.
d. The anteroapical region is demonstrating a slow rhythm.
ANS: B
Anterioapical hypokinesis means the anteroapical region is moving sluggishly, indicating an
area that is severely ischemic and possibly injured.

PTS: 1

24. Which of the following ankle brachial index (ABI) values indicates severe arterial occlusive
disease and high cardiovascular risk?
a. 1.1
b. 0.9
c. 0.8
d. 0.5
ANS: D
An ABI above 0.9 is considered normal. An ABI below 0.5 is suggestive of severe arterial
occlusive disease.

PTS: 1

25. A patient is positioned in supine and her legs are elevated to 45 degrees. In this position the
therapist assesses the color of the legs, then places the leg in a dependent position to again
assess the color. This procedure describes which of the following tests?
a. Venous filling time test
b. Rubor dependency test
c. Trendelenburg test
d. Homan’s sign
ANS: B
The question describes a rubor dependency test. If the leg turns a pale color in the elevated
position, arterial insufficiency is suggested. If the color of the leg in a dependent position is a
deep red color (rubor) after 30 seconds, arterial insufficiency is again suspected.
 PTS: 1

26. A patient is undergoing a maximal exercise test in the laboratory. During the third stage of the
treadmill maximal exercise test, the therapist notes the patient appears to be mildly confused
and is less coordinated walking on the treadmill. Which of the following should be the next
action of the therapist?
a. The therapist should straddle the treadmill and provide close contact guard of the
patient to prevent a fall.
b. The therapist should immediately obtain a heart rate and blood pressure reading.
c. The therapist should terminate the test.
d. The therapist should ask the patient if he can continue the test.
ANS: C
Signs of dizziness, mental confusion, or lack of coordination are criteria for terminating a
maximal exercise test.

PTS: 1

27. Which of the following diagnostic tests would be indicated to evaluate vascular dysfunction?
a. Arterial duplex ultrasonography
b. Echocardiography
c. Pharmacological stress testing
d. Exercise ECG
ANS: A
Arterial duplex ultrasonography is a more precise diagnostic test for defining arterial stenoses
and occlusions. Echocardiography evaluates value integrity, ventricular size, ejection fraction,
and cardiac muscle pump function; pharmacological stress testing evaluates ischemia;
exercise ECG evaluates rhythm abnormalities.

PTS: 1

28. Which of the following values is considered a high-risk factor for coronary artery disease?
a. Homocysteine level of 10.0 μmol/L
b. C-reactive protein level of 3.2 mg/L
c. Glucose level of 92 mg/dL
d. Hb A1c of 5.5%
ANS: B
A C-reactive protein level of >3.0 mg/L is considered high risk. All other listed values were
within normal range.

PTS: 1

29. Which of the following target international normalized ratio (INR) values for anticoagulative
therapy is MOST appropriate for patients with prosthetic heart valves?
a. 1.8 (1.5–2.0)
b. 2.5 (2.0–3.0)
c. 3 (2.5–3.5)
d. 3.5 (3.0–4.0)
 ANS: C
Patients post-MI or with a mechanical valve have a target INR of 3 (2.5–3.5) and all other
clotting problems have a target INR of 2.5 (2.0–3.0).

PTS: 1

TRUE/FALSE

1. Elevated CK-MB levels in a patient after a hip surgery confirms the patient experienced some
level of myocardial injury.

ANS: F
Elevated CK-MB levels in a patient after hip surgery could be related to the size of the
implant and the related reaming and heating effect. To confirm myocardial injury, this same
patient with elevated CK-MB levels must also have elevated troponin levels. If a concurrent
elevated troponin level is not present, myocardial injury is unlikely and patient activity level
can be increased as tolerated.

PTS: 1