CV Flashcards
A 45-year-old man was rushed to the hospital following the sudden onset of an episode of crushing substernal chest pain. He receives advanced life support measures. His course was marked by intractable cardiogenic shock and he died 4 days later. At autopsy, a large transmural anterolateral area of coagulative necrosis was found in the anterolateral wall of the left ventricle. Which of the following microscopic findings is most likely to be present?
A Fibroblasts and collagen
B Granulation tissue
C Necrotic muscle and neutrophils
D Granulomatous inflammation
E Diffuse chronic inflammation
C
What disease are mutations in the following genes assc with? A Beta-myosin B CFTR D Fibrillin F Dystrophin
A: dilated cardiomyopathy
B: cor pulmonale (CF)
D: mitral valve prolapse, aortic dissection
F: duchenne MD –> cardiac failure
A 72-year-old woman has had no major illnesses throughout her life. She has had 3 syncopal episodes over the past 2 weeks. Over the past 2 days she has developed shortness of breath and a cough with production of frothy white sputum. On physical examination she is afebrile. Her blood pressure is 135/90 mm Hg. She has no peripheral edema. A chest radiograph reveals a prominent left heart border in the region of the left ventricle, but the other chambers do not appear to be prominent. There is marked pulmonary edema. Laboratory studies show a total serum cholesterol of 170 mg/dL. Which of the following is the most likely diagnosis?
calcific aortic stenosis
A 17-year-old girl is brought to the physician because she remains short in stature for her age. She has not shown any changes of puberty. On physical examination her vital signs include T 37 C, RR 18/minute, P 75/minute, and BP 165/85 mm Hg. She has a continuous murmur heard over both the front of the chest as well as her back. Her lower extremities are cool with poor capillary filling. She has a webbed neck. A chest radiograph reveals a prominent left heart border, no edema or effusions, and rib notching. Which of the following cardiovascular abnormalities is she most likely to have?
A Shortening and thickening of chordae tendineae of the mitral valve
B Constriction of the aorta past the ductus arteriosus
C Supravalvular narrowing in the aortic root
D Lack of development of the spiral septum and partial absence of conus musculature
E Single large atrioventricular valve
B: She has coarctation of the aorta, and the constriction is postductal, allowing prolonged survival. Her physical characteristics also suggest Turner syndrome (monosomy X).
A 24-year-old woman with rheumatic heart disease becomes febrile. On physical examination she has a systolic murmur. An echocardiogram shows vegetations of the aortic valve cusps. A blood culture is positive for Staphylococcus epidermidis. She receives a porcine bioprosthesis because of her desire to have children and not to take anticoagulant medication. After ten years, she must have this prosthetic valve replaced. Which of the following pathologic findings in the bioprosthesis has most likely led to the need for replacement?
A Dehiscence
B Endocarditis
C Strut failure
D Calcification
E Thrombosis
D:
Patients with mechanical prostheses are given anticoagulant therapy, but persons with bioprostheses do not need this medication.
Dehisence, when the suture margin comes loose, is a rare complication that manifests soon after the surgery.
A 25-year-old previously healthy woman dies suddenly and unexpectedly. She had complained only of a slight headache for 3 days before her demise. At autopsy, the medical examiner finds an enlarged, dilated 410 gm heart with only minimal coronary atherosclerosis and normal cardiac valves. Microscopically, the myocardium on both the right and the left ventricles demonstrates infiltration by small lymphocytes, with focal myocyte necrosis. Which of the following infectious agents is most likely to have caused these findings?
A Coxsackie B virus
B Candida albicans
C Aspergillus fumigatus
D Streptococcus, viridans group
E Staphylococcus aureus
F Cytomegalovirus
G Streptococcus, group A
A The most common cause for a primary myocarditis is a virus (such as Coxsackie virus). Viral myocarditis can be a cause for sudden death in a young person.
A 2-year-old child has had failure to thrive for a year, becoming increasingly listless. On examination she is found to have a soft, rumbling systolic ejection murmur. An echocardiogram reveals a large membranous ventricular septal defect. Which of the following complications is she most likely to experience as an adult 2 decades later if this lesion remains untreated?
A Rib notching
B Mitral valve prolapse
C Pulmonary hypertension
D Myocardial infarction
E Cardiac tamponade
C: The left-to-right shunt eventually leads to pulmonary hypertension and reversal of the shunt (Eisenmenger complex)
A 25-year-old previously healthy woman has had worsening fatigue with dyspnea, palpitations, and fever over the past week. On physical examination her vital signs show T 38.9 C, P 103/minute, RR 30/minute, and BP 95/65 mm Hg. Her heart rate is slightly irregular. An ECG shows diffuse ST-T segment changes. A chest x-ray shows mild cardiomegaly. An echocardiogram shows slight mitral and tricuspid regurgitation but no valvular vegetations. Laboratory studies show a troponin I of 12 ng/mL. She recovers over the next two weeks with no apparent sequelae. Which of the following laboratory test findings best explains the underlying etiology for these events?
A Anti-streptolysin O titer of 1:512
B Total serum cholesterol of 537 mg/dL
C Coxsackie B serologic titer of 1:160
D Blood culture positive for Streptococcus, viridans group
E ANCA titer of 1:80
C
A 44-year-old man has had no major medical problems throughout his life, except for arthritis pain involving all extremities for the past 5 years. He has had worsening orthopnea and pedal edema in the past 6 months. There is no chest pain. On examination he is afebrile. A chest radiograph shows cardiomegaly with both enlarged left and right heart borders, along with pulmonary edema. Laboratory studies show serum sodium 139 mmol/L, potassium 4.3 mmol/L, chloride 99 mmol/L, CO2 25 mmol/L, urea nitrogen 18 mg/dL, creatinine 1.3 mg/dL, and glucose 167 mg/dL. Which of the following additional laboratory test findings is he most likely to have?
A Spherocytes on his peripheral blood smear
B Hemoglobin of 10.7 g/dL with MCV of 72 fL
C Erythrocyte sedimentation rate of 79 mm/Hr
D Anti-centromere antibody titer of 1:320
E Serum ferritin of 8700 ng/mL
E: Hereditary hemochromatosis can produce iron deposition in visceral organs, including the heart. The serum ferritin is a good indicator of body iron stores. Hemochromatosis affects the pancreas as well, leading to diabetes mellitus. Deposition of iron in joints leads to arthritis. The onset of disease is typically in the 40’s in males and 60’s in females.
A) Incorrect. Spherocytosis can lead to a mild hemolytic anemia that stresses the heart somewhat to produce mild hypertrophy.
(B) Incorrect. An iron deficiency anemia in an adult could chronically lead to increased cardiac output. If severe enough, there could be a high-output cardiac failure. The heart will tend to enlarge somewhat. This does not explain his arthritis or hyperglycemia, though.
While playing cards, a 63-year-old woman has the sudden onset of “knife-like” pain in the chest radiating to the back. She has been previously healthy except for a history of poorly controlled hypertension. Paramedics are called, and she is transported to the hospital. On admission, she has a heart rate of 90/minute, respirations 20/minute, temperature 36.8 C, and blood pressure 150/100 mm Hg. No murmurs, rubs, or gallops are audible. A chest radiograph reveals a widened mediastinum. Laboratory findings include a total serum creatine kinase of 55 U/L, creatinine 0.9 mg/dL, and glucose 123 mg/dL. Which of the following is the most likely diagnosis?
A Fibrinous pericarditis
B Aortic intimal tear
C Infective endocarditis
D Dilated cardiomyopathy
E Myocardial infarction
(B) CORRECT. This is a classic history for an aortic dissection. A tear in the aortic intima is followed by dissection of blood outward, often to the thoracic cavity, with fatal hemothorax. The risk factors in most adults include atherosclerosis and hypertension. In Marfan syndrome, the risk for aortic dilation and dissection results from cystic medial necrosis, but this occurs at a much younger age.
(A) Incorrect. A pericarditis can produce pain, but not typically knife-like and not suddenly.
(D) Incorrect. Cardiomyopathies are not typically associated with chest pain.
A 35-year-old man was found down and was delirious and talking incoherently. On examination in the emergency department his temperature is 39.3 C, pulse 110/minute, and blood pressure 70/palpable. He has a heart murmur, palpable spleen tip, and splinter hemorrhages of fingernails. Which of the following laboratory findings is most likely to be present in this man?
A Positive urine screen for opiates
B Elevated anti-streptolysin O (ASO)
C Increased urinary free catecholamines
D Elevated Coxsackie B viral titer
E Rising creatine kinase (CK) in serum
(A) CORRECT. This history points to an infective endocarditis. A common risk factor for infective endocarditis is intravenous drug use.
A 69-year-old woman with a 7 kg weight loss over the past 6 months now has developed painless jaundice over the past 2 weeks. On physical examination she is afebrile. An abdominal CT scan shows a large mass involving the head of the pancreas, along with widespread nodules in the liver. Nodules are seen in both lungs by chest radiograph. Which of the following cardiac lesions is she most likely to develop?
A Dilated cardiomyopathy
B Non-bacterial thrombotic endocarditis
C Acute fibrinous pericarditis
D Endocardial fibrosis
E Acute myocardial infarction
(B) CORRECT. Such cancers can be associated with a hypercoagulable state (Trousseau’s syndrome) with formation of marantic cardiac valvular vegetations.
**lung cancer also can cause pericardial effusion!!
A 51-year-old woman has had several syncopal episodes over the past year. Each episode is characterized by sudden but brief loss of consciousness. She has no chest pain. On physical examination her vital signs show T 36.9 C, P 80/minute, RR 20/minute, and BP 110/75 mm Hg. She has no pedal edema. On brain MR imaging there is a 1.5 cm cystic area in the left parietal cortex. A chest radiograph shows no cardiac enlargement, and her lung fields are normal. Her serum total cholesterol is 165 mg/dL. Which of the following cardiac lesions is she most likely to have?
A Cardiac amyloidosis
B Left atrial myxoma
C Tuberculous pericarditis
D Mitral valve prolapse
E Ischemic cardiomyopathy
(B) CORRECT. Atrial myxomas are more often on the left. Though benign, they can occlude the mitral valve and produce sudden loss of cardiac output. They may embolize small portions of themselves or thrombus forned over their surface.
A 25-year-old man dies suddenly and unexpectedly while at a Beverly Hills (or Kings Cross, or Soho…) nightclub late one evening. The medical examiner performs an autopsy. There is no evidence for trauma on external examination of the body. There are no gross pathologic findings of internal organs. Postmortem toxicologic findings are significant for high blood levels of cocaine and its metabolite benzoylecgonine. Which of the following is the most likely histopathologic finding involving his heart?
A Contraction band necrosis
B Myocarditis
C Myofiber disarray
D Coronary thrombosis
E Pericardial tamponade
(A) CORRECT. This finding has been associated with sudden death and cocaine use. It is thought that it may be mediated by high norepinephrine levels.
Post MI, when are the following complication likely to occur?
Thromboemolism
Rupture
Arrythmia
weeks to months
5 days
1 day
