American College of Physicians: Internal Medicine — Doctors for Adults ®


The MKSAP Challenge

From the May ACP Observer, copyright 2006 by the American College of Physicians.

Clinical Scenario

A 58-year-old man with a history of congestive heart failure develops psoriatic arthritis. He has chronic stable exertional dyspnea but no chest pain or orthopnea. Medications are warfarin, aspirin, a statin, an angiotensin-converting enzyme inhibitor and a beta-blocker.

On physical examination, pulse rate is 66/min and irregular, respiration rate is 12/min, and blood pressure is 130/60 mm Hg. There is no jugular venous distention, and the lungs are clear to auscultation. An electrocardiogram reveals atrial fibrillation, a previous anterior myocardial infarction and an incomplete left bundle-branch block. An echocardiogram shows a left ventricular ejection fraction of 38%.

Which of the following is a contraindication for initiating infliximab therapy in this patient?

A. Atrial fibrillation
B. Cardiac conduction abnormality
C. Decreased ejection fraction
D. Ischemic heart disease



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