Cardiology

Question 1

Warfarin and pregnancy

Answer 1

Warfarin is associated with teratogenicity (eg, skeletal abnormalities) and can cross the placental barrier, leading to fetal bleeding.

Low-dose warfarin ≤5 mg/day appears to provide a higher safety margin, and continuing this regimen throughout pregnancy (including the first trimester) is a potential option for pregnant patients with mechanical heart valves.

However, pregnant patients with any other indication for anticoagulation (eg, atrial fibrillation, venous thromboembolism) and those with higher dose requirements (>5 mg/day) should be managed with subcutaneous LMWH

Question 2

Statin myopathy

Answer 2

Statin myopathy commonly occurs due to drug-drug interactions and usually resolves after discontinuing the statin.

After resolution of myopathy, patients requiring aggressive cholesterol lowering should be restarted on an alternate statin with a lower myopathic potential (eg, rosuvastatin, pravastatin, fluvastatin).

Question 3

Post CABG mediastinitis

Answer 3

Postoperative mediastinitis typically occurs within the first 2 weeks after surgery and presents with fever, tachycardia, chest pain, and signs of sternal wound infection, such as purulent discharge.

Question 4

Post cardiac injury syndrome

Answer 4

likely an autoimmune reaction, causing inflammation and presenting with the typical symptoms of pericarditis. Treatment includes NSAIDs or steroids. Prophylactic colchicine after cardiac surgery significantly decreases the incidence of PCIS.

Question 5

Aortic dissection complications

Answer 5

Stroke (carotid artery)

• Horner syndrome (carotid sympathetic plexus)

• Acute aortic regurgitation (aortic root/valve)

• Myocardial ischemia/infarction (coronary artery ostia)

• Pericardial effusion/tamponade (pericardium)

• Hemothorax (pleural cavity)

• Renal infarction (renal arteries)

• Intestinal ischemia (mésenteric arteries)

• Lower extremity paralysis (spinal arteries)

Question 6

Mitral stenosis

Percutaneous mitral balloon valvotomy indications

Answer 6

Severe mitral stenosis (valve area ≤1.5 cm²) & ≥1 of the following:
• Symptoms (eg, dyspnea, orthopnea)
• Pulmonary artery systolic pressure >50 mm Hg

Question 7

Mitral valve stenosis

Percutaneous mitral valve balloon valvotomy contraindications

Answer 7

• Moderate or severe mitral regurgitation
• Complex valve anatomy
• Extensive valve calcification
• Left atrial thrombus

They should proceed with surgical mitral valve repair/replacement

Question 8

Anti platelets post coronary stenting
Recommended duration

Answer 8

• DAPT for minimum of 6-12 months after BMS or DES placement
• DAPT for minimum of 4 weeks in select patients after BMS
• Continue DAPT for a total of 30 months if possible (eg, low bleeding risk)
• Continue aspirin indefinitely

Question 9

Dual anti platelets perioperative management

Answer 9

• Elective surgery: defer procedure until after minimum DAPT duration
• Urgent surgery: continue P2Y12 receptor blocker or hold for shortest duration possible
• Continue aspirin unless high risk of severe surgical bleeding

Question 10

Plavix pre CABG

Answer 10

The use of P2Y12 inhibitors within 5-7 days of coronary artery bypass graft (CABG) is associated with an increased risk of significant bleeding, with increased requirements for blood transfusion and possible reoperation; current guidelines recommend that these agents be discontinued at least 5-7 days before CABG

Question 11

Peripheral arterial disease management (Part 1)

Answer 11

-Modifying risk factors (especially smoking cessation)
-adding graded exercise therapy can improve symptoms and decrease the progression of disease.

-Antiplatelet therapy is the preferred initial therapy for PAD, and aspirin is the preferred drug .

-Clopidogrel is typically used in patients who cannot tolerate aspirin.

Question 12

Peripheral arterial disease management (Part 2)

Answer 12

-Patients who are still symptomatic on antiplatelet therapy require second-line agents such as cilostazol, a phosphodiesterase inhibitor and vasodilator that inhibits platelet aggregation and significantly increases maximal and pain-free walking distances.

-Cilostazol is contraindicated in patients with heart failure due to increased mortality in these patients.

Question 13

Choice of stress testing in intermediate risk CAD

Answer 13

Pharmacologic radionuclide perfusion imaging should be performed to evaluate suspected coronary heart disease in patients with paced ventricular rhythm or left bundle branch block.

Question 14

Papillary muscles rupture

Answer 14

Papillary muscle rupture may occur acutely or within 3-5 days of acute myocardial infarction, most commonly one that affects the inferior wall. Patients have rapid-onset pulmonary edema and cardiogenic shock due to acute mitral regurgitation. A new holosystolic murmur is often, but not always, present

Question 15

Hypertrophic cardiomyopathy definition

Answer 15

Defined as left ventricular wall thickness ≥15 mm (1.5 cm) at any location in the absence of other potential causes (eg, hypertension, valvular heart disease).

Question 16

Hypertrophic cardiomyopathy presentation

Answer 16

Patients with HCM may remain asymptomatic, or they may develop dyspnea, orthopnea, palpitations, chest pain, dizziness, or syncope.

Exertional myocardial ischemia can lead to sustained ventricular arrhythmia and sudden cardiac death (SCD);

HCM is the most common cause of SCD in young athletes.

Question 17

Hypertrophic cardiomyopathy initial management

Answer 17

To lower the risk of SCD, patients with probable or definite HCM should not participate in high-intensity competitive sports regardless of the presence of symptoms, degree of wall thickness or left ventricular outflow tract (LVOT) obstruction, or prior treatment.

Question 18

Hypertrophic cardiomyopathy ICD indication

Answer 18

An implantable cardioverter defibrillator (ICD) is generally indicated for primary prevention in patients with risk factors for SCD (eg, left ventricular wall thickness >30 mm, family history of SCD due to HCM) and for secondary prevention in patients who survive an episode of sustained ventricular arrhythmia.

Question 19

Hypertrophic cardiomyopathy medical management

Answer 19

Medical therapy with negative inotropic agents (eg, beta blockers, nondihydropyridine calcium channel blockers, disopyramide) is recommended in patients with LVOT obstruction and symptoms of heart failure.

Dihydropyridine calcium channel blockers (eg, amlodipine, nifedipine) as well as other vasodilators (eg, ACE inhibitors) and diuretics should be avoided in patients with HCM as they decrease afterload and can worsen LVOT obstruction and symptoms.

Question 20

Hypertrophic cardiomyopathy surgical management

Answer 20

Alcohol septal ablation or surgical septal myectomy is indicated for HCM patients with severe LVOT obstruction (resting or Valsalva gradient >50 mm Hg) and heart failure symptoms that are refractory to optimal medical therapy

Question 21

Central sleep apnea

Answer 21

Central sleep apnea with Cheyne-Stokes breathing is a potential complication in patients with heart failure. Treatment includes positive airway pressure therapy and supplemental oxygen.

Question 22

Peripartum cardiomyopathy Risk factors

Answer 22

• Maternal age >30
• Multiple gestation
• Eclampsia or preeclampsia
- maternal cocaine use
- African descent

Question 23

Peripartum cardiomyopathy presentation

Answer 23

• Left ventricular ejection fraction <45%
• Onset at ≥36 weeks gestation or ≤5 months postdelivery
• No other causes of heart failure

Question 24

Peripartum cardiomyopathy management

Answer 24

• Urgent delivery if hemodynamic instability present
• Standard management of heart failure with reduced ejection fraction (eg, beta blocker, diuretics) Avoid ARBs/ACEI during pregnancy

• Patients who recover LV function to normal have a lower risk of complications during subsequent pregnancies, but their risk is still elevated when compared to the general population.

Patients with persistent LV dysfunction have a substantially higher risk of complications such as significant decline in LVEF, recurrent heart failure, and death and should avoid subsequent pregnancies.

Question 25

Atrial flutter management

Answer 25

Radiofrequency ablation has an excellent success rate in restoring and maintaining sinus rhythm in patients with typical atrial flutter. It is generally preferred over long-term antiarrhythmic agents as a safe and effective first-line treatment in such patients.

Question 26

Congenital long QT syndrome
-Jervell & Lange-Nielsen syndrome (autosomal recessive)
-Romano-Ward syndrome (autosomal dominant)
Management

Answer 26

Management includes avoidance of conditions (eg, strenuous exercise, electrolyte abnormalities such as hypokalemia or hypomagnesemia) and medications (eg, antipsychotics, fluoroquinolones) that may prolong the QT interval. Current guidelines also recommend that all patients with congenital LQTS (symptomatic or asymptomatic) be treated with beta blockers (eg, propanolol, nadolol) to decrease the risk of symptomatic arrhythmias and sudden cardiac death

Question 27

Digoxin toxicity treatment

Answer 27

Treatment depends on the severity of symptoms.
Digoxin cannot be removed by hemodialysis. If rapid treatment is needed, digoxin-specific Fab antibody fragments can reverse toxicity within 4 hours

Question 28

Digoxin toxicity pitfalls

Answer 28

Cardioversion can increase intracellular calcium and possibly increase ventricular arrhythmias in the setting of digoxin toxicity.

If present, some degree of hypocalcemia should be tolerated in these patients, as calcium replacement can also increase intracellular calcium.

Question 29

Approach of ACS post PCI + A.fib with high risk of GI bleed

Answer 29

Double therapy with a P2Y12 inhibitor (clopidogrel or ticagrelor) and low-dose rivaroxaban (or dose-adjusted warfarin) is reasonable antithrombotic prophylaxis in patients with atrial fibrillation at higher risk of bleeding after stent placement for acute coronary syndrome.

Question 30

Mitral stenosis assessment

Answer 30

Patients with mitral stenosis who have a discrepancy between clinical findings and echocardiographic findings should undergo exercise echocardiography to ensure that symptoms can be attributed to mitral stenosis.

Question 31

Cardiac tamponade on ECHO

Answer 31

The right atrium has the lowest pressure of all cardiac chambers; therefore, right atrial collapse during end diastole is the earliest and most sensitive sign of cardiac tamponade. Right ventricular diastolic collapse is less sensitive than right atrial diastolic collapse, but is highly specific for the presence of cardiac tamponade.

Question 32

Digoxin toxicity and hyperkalemia

Answer 32

Digoxin toxicity causes excessive inhibition of the sodium- potassium-ATPase in cardiac myocytes, leading to hyperkalemia.

The hyperkalemia itself does not cause death, but it is a marker of severity and a predictor of mortality in acute digoxin toxicity.
Therefore, therapy in these patients should be aimed at lowering serum digoxin levels; medications to treat hyperkalemia (eg, calcium gluconate, insulin) are not indicated and may lead to hypokalemia as therapy with Fab fragments rapidly lowers potassium levels

Question 33

Aortic dissection treatment

Answer 33

• Pain control (eg, morphine)
• Intravenous beta blockers (eg, esmolol)
• ± Sodium nitroprusside (if SBP >120 mm Hg despite beta blockers)
• Emergency surgical repair for ascending dissection

Question 34

Multifocal atrial tachycardia

Answer 34

Causes
• Exacerbation of pulmonary disease (eg, COPD)
• Electrolyte disturbance (eg, hypokalemia)
• Catecholamine surge (eg, sepsis)
Clinical findings
• Typically asymptomatic
• Rapid, irregular pulse
• ECG: ≥3 P-wave forms & atrial rate >100/min
Treatment
• Correct underlying disturbance
• AV nodal blockade (eg, verapamil) if persistent

Question 35

Cocaine use MI management

Answer 35

• Aspirin
• Nitroglycerin and calcium channel blockers for pain
• Beta blockers contraindicated
• Benzodiazepines for blood pressure and anxiety
• Fibrinolytics not preferred due to increased intracranial hemorrhage risk
• Immediate cardiac catheterization with reperfusion when indicated

Question 36

Stages of pericarditis on the ECG

Answer 36

Stage 1, usually seen within the first few hours, is characterized by diffuse, concave upward ST segment elevation across the precordial and limb leads, along with reciprocal ST depression in leads aVR and V1. The PR segment is elevated in aVR, with depression in other limb leads. The presence of PR segment changes is thought to be very specific for acute pericarditis.

Stage 2 represents normalization of the ST and PR segment changes, and is usually seen within the first few days.

Stage 3 is characterized by the presence of diffuse T wave inversions.

Stage 4 is distinguished by either normalization of the ECG or the persistence of T wave inversions over the next few weeks.

Question 37

Indications for Pacemaker implantation

Answer 37

1)Symptomatic bradycardia without reversible cause;
2)Permanent atrial fibrillation with symptomatic bradycardia
3)alternating bundle branch block
4)complete heart block
5)high degree atrioventricular (AV) block
6)Mobitz type 2 second degree AV block

Question 38

ICD Implantation for Secondary prevention

Answer 38

Patients with sustained ventricular arrhythmias (>30 seconds) or cardiac arrest without a reversible cause
have a class 1 recommendation for secondary prevention
with implantable cardioverter-defibrillator placement.

Question 39

A.fib and early rhythm control

Answer 39

In patients with recently diagnosed atrial fibrillation (<12months) and concomitant cardiovascular conditions, –> early rhythm control (antiarrhythmic drugs or ablation) reduces the primary composite end point of cardiovascular death, stroke, or hospitalization for heart failure or acute coronary syndrome compared with usual care.(Rate control only)

Question 40

Cardiac angiosarcoma

Answer 40

–rare malignant cardiac tumor often presents with symptoms of dyspnea and chest pain
–generally arises in the right heart. most commonly the right atrium.
–Tamponade and bloody pericardial fluid are typical.
–Metastasis to the lungs, liver,
lymphatic system. bone. and adrenal glands is commonly present at the time of diagnosis.
–Pericardiocentesis with
cytologic examination is of negative for malignant cells
–Tissue biopsy is frequently required for diagnosis.
–Surgical resection and adjuvant chemotherapy or radiotherapy should be considered.

Question 42

Atrial myxomas

Answer 42

Atrial myxomas occur most commonly within the left atrium and with association to the inter- atrial fossa, although they may present in other locations, including the right atrium. They typically cause constitutional symptoms of fever, weight loss, and fatigue; embolic phenomena; or symptoms related to obstruction. Pericardial effusion with tamponade would be an exceptionally rare presentation of atrial myxoma

Question 43

Complicated Type B aortic dissection

Answer 43

• Complicated type B aortic dissection is characterized by limb or end-organ ischemia, persistent severe hypertension, persistent pain, propagation of the dissection, enlargement of the descending aorta, and/or rupture of the aorta.

• Complicated type B aortic dissection is an indication for immediate vascular intervention. (Thoracic endovascular aortic repair)

Question 44

Cardiovascular risk reduction in peripheral arterial disease

Answer 44

• In patients with peripheral artery disease, antithrom- botic therapy with very low-dose rivaroxaban plus aspirin reduces the occurrence of cardiovascular death, myocardial infarction, or stroke by 2% and increases the risk for major bleeding by 1%.

• No study has demonstrated the benefit of intensifying lipid management when the LDL cholesterol level is below 70 mg/dL (1.81 mmol/L).

Question 45

Patent ductus arteriosus
Definition and presentation

Answer 45

🔴A PDA is a persistent fetal connection between the aorta and the left pulmonary artery that leads to volume overload of the left-sided chambers, manifested by left atrial and left ventricular enlargement.

🔴The typical murmur of a PDA is a continuous “machinery” murmur that envelops the S₂, making it inau- dible; the murmur is heard beneath the left clavicle

Question 46

Patent ductus arteriosus
Indication for closure

Answer 46

🔴Closure of the PDA is indicated in patients with left-sided cardiac chamber enlargement as long as pulmonary artery systolic pressure is less than 50% systemic,

🔴PDA closure in patients with severe pulmonary hypertension (pulmonary artery systolic pres- sure >66% systemic) is associated with greater risk and is not associated with improved survival. In patients with pulmonary hypertension, the existence of right-to-left ductal shunting may be necessary to maintain cardiac output, and closure may result in clinical worsening

Question 47

Ventricular tachycardia

Answer 47

In adult patients with structural heart disease, 95% of wide-complex tachycardias are ventricular tachycardia

Question 48

Trastuzumab cardiomyopathy

Answer 48

The 2017 American Society of Clinical Oncology (ASCO) practice guideline recommends echocardiography as the surveillance imaging modality of choice. A
SCO identifies patients receiving trastuzumab as having increased risk for cardiac dysfunction if any of the following are present:
🔴two or more traditional cardiovascular risk factors (smoking, hypertension, diabetes mellitus, dyslipidemia, and obesity),
🔴older age (>60 years) at cancer treatment, 🔴borderline left ventricular ejection fraction (50% to 55%),
🔴history of myocardial infarction,
🔴moderate or greater valvular heart disease,
🔴treatment combined with lower-dose anthracycline

Question 49

Acute limb ischemia

Answer 49

• Classically, patients with acute limb ischemia present with at least one of the six P’s: paresthesia, pain, pal- lor, pulselessness, poikilothermia (coolness), and paralysis.

• Patients with acute limb ischemia should receive emergent systemic anticoagulation and diagnostic angiography in preparation for revascularization

Question 50

Spontaneous coronary artery dissection (SCAD)

Answer 50

🔴SCAD is the most common cause of pregnancy-associated myocardial infarction and commonly occurs during pregnancy or in the first month postpartum.

🔴SCAD involves development of a nontraumatic and non-iatrogenic intramural hematoma with or without intimal dissection with luminal communication. The enlarging hematoma in the false lumen compresses the true lumen of the coronary artery and in potential combination with obstructing dissection leads to chest pain, ischemia, and/or infarction.
🔴The diagnosis requires coronary CT or coronary angiography to confirm the characteristic imaging features.
🔴When associated with ST-elevation myocardial infarction, SCAD may be managed invasively; however, percutaneous coronary intervention may be safely deferred when coronary flow is preserved and symptoms can be controlled and closely monitored.

Question 51

Heart failure follow up

Answer 51

Two key elements are associated with a successful transition to home following hospitalization for heart failure: a follow-up phone call within 2 to 3 days of discharge and an office visit within 7 to 14 days of hospital discharge.

Question 52

Aortic stenosis discrepancy on Echo
(Between size and hemodynamics)

Answer 52

• Guidelines recommend cardiac catheterization to evaluate patients with suspected significant aortic ste- nosis when there is a discrepancy between the clinical evaluation and the echocardiogram.

🔴🔴Exercise stress testing is contraindicated in most patients with symptomatic severe aortic stenosis, given the increased risk for sudden cardiac death during the test

Question 53

Symptomatic PVCs

Answer 53

• First-line treatment for symptomatic premature ven- tricular contraction suppression is ẞ-blocker or calcium channel blocker therapy; B-blockers are preferred in patients with ventricular dysfunction.

• Ambulatory ECG monitoring can help clarify the bur- den of premature ventricular contractions (PVCs); patients with PVCs that account for more than 10% to 15% of beats may be at risk for PVC-induced cardiomyopathy.

Question 54

Stress testing in patients with LBBB

Answer 54

• In the evaluation of patients with chest pain, vasodila- tor myocardial perfusion imaging with adenosine, regadenoson, or dipyridamole minimizes septal abnormalities frequently seen with exercise or dobu- tamine myocardial perfusion imaging.

Question 55

ECG findings that impairs exercise ecg interpretation

Answer 55

ST-segment depression greater than 1mm,
left bundle branch block,
left ventricular hypertrophy,
paced rhythm
preexcitation.

Question 56

Cardiac sequelae of Radiation therapy

Answer 56

• Cancer survivors who received chest radiotherapy are at risk for the late development of cardiovascular complications, including pericardial constriction, valvular heart disease, restrictive cardiomyopathy, and coronary artery disease.

Question 57

Mitral regurgitation discrepancy

Answer 57

• For patients in whom there is a discrepancy between physical examination findings and transthoracic echo- cardiographic assessment of mitral regurgitation severity, cardiac magnetic resonance imaging or transesophageal echocardiography should be used to quantitatively assess mitral regurgitation and resolve the discrepancy

Question 58

Tetralogy of Fallot and pulmonary regurgitation

Answer 58

• Severe pulmonary regurgitation causes a diastolic murmur heard at the left sternal border that increases in intensity with inspiration, a parasternal lift, and a soft systolic pulmonary outflow murmur.

• Pulmonary regurgitation is the most common postop- erative sequela of tetralogy of Fallot repair.

Question 59

When to admit acute pericarditis

Answer 59

high-risk features, including 🔴temperature higher than 38.0 °C (100.4 °F),
🔴subacute onset,
🔴a large pericardial effusion (>2cm) 🔴tamponade at presentation,
🔴oral anti-coagulation therapy,
🔴lack of response to treatment

Question 60

Coronary vasospasm

Answer 60

🔴Coronary vasospasm occurs either spontaneously from vasomotor dysfunction or after exposure to drugs (such as cocaine or chemotherapeutic agents) and is often a diagnosis of exclusion.
🔴Invasive testing with coronary angiography may not reveal spontaneous vasoconstriction, and additional provocative testing with acetylcholine or ergonovine infusion may be necessary to confirm an abnormal vasoconstrictive response. . 🔴ECG patterns may be nonspecific or suggest ST-elevation myocardial infarction.
🔴Severe cases of multivessel spasm may be associated with widespread ST-segment elevation and possibly ventricular dysrhythmia and cardiac arrest.
🔴Treatment with calcium channel blockade and/or nitrates can rapidly reverse coronary vaso- constriction, with improvement in myocardial perfusion. symptoms, ECG abnormalities, and hemodynamics

Question 61

Chronic limb threatening ischemia

Answer 61

Chronic limb-threatening ischemia is characterized by more than 2 weeks of ischemic rest pain, nonhealing wound/ulcers, or gangrene in one or both legs that is attributable to objectively proven peripheral artery disease.

In patients with chronic limb-threatening ischemia, immediate invasive angiography with endovascular revascularization is often the most effective strategy to preserve tissue viability.

Question 62

Aortic valve regurgitation surgery indication

Answer 62

• In symptomatic patients with severe aortic regurgitation, aortic valve surgery is indicated regardless of left ventric- ular systolic function.

• In asymptomatic patients with chronic severe aortic regurgitation and left ventricular systolic dysfunction (ejection fraction ≤55%), aortic valve surgery is indi- cated.

Question 63

Ebstein anomaly

Answer 63

Ebstein anomaly is a congenital heart condition that may manifest in adulthood with clinical features including electrocardiographic abnormalities such as supraventricular arrhythmias or ventricular preexcitation. (WPW)

Question 64

Stent thrombosis vs stenosis

Answer 64

Acute stent thrombosis refers to the formation of a thrombus within or immediately adjacent to a previously placed coronary artery stent Acute stent thrombosis typically causes ST-segment elevation myocardial infarction (STEMI) and is often life-threatening Risk factors for acute stent thrombosis include previous stent placement during acute coronary syndrome, diabetes mellitus, chronic kidney disease, depressed left ventricular systolic function, and premature cessation of dual antiplatelet therapy .

In-stent restenosis a process of neointimal hyperplasia that occurs gradually (usually over the course of months) within coronary stents may result in angina or an acute coronary syndrome but is rarely a cause of STEMI

Question 65

Erythrocytosis management in ACHD

Answer 65

In an adult with cyanotic congenital heart disease and erythrocytosis, therapeutic phlebotomy is indicated if the hematocrit exceeds 65% (hb>20) with symptoms of hyperviscosity in the absence of volume depletion

Question 66

Adenosine contraindications

Answer 66

Because of the risk for high-grade AV block, standard-dose adenosine is contraindicated in patients who have second-or third-degree AV block or sick sinus syndrome but who do not have a pacemaker. Heart transplant recipients are particularly sensitive to the AV-blocking effects of adenosine, so the standard dose of the drug is contraindicated in these patients. A

lower dose of adenosine (3 mg) is recommended in cardiac transplant

recipients.

Adenosine can be administered with caution (ie, with continuous electrocardiographic monitoring) in patients with preexisting first-degree heart block, because development of high-grade block is rare in such patients and is transient when it occurs

Question 67

Kawasaki disease complications

Answer 67

The most dangerous complication of Kawasaki disease is the formation of coronary artery aneurysms, which over time can cause myocardial infarction
secondary to thrombosis or stenosis. This complication is rare but is seen more commonly in men than in women