Learning Cardiology

Q. Which of the following is false about Takayasu arteritis? A. Strong female predominance B. Increased prevalence in western counties as compared to Asians C. Pulmonary artery involvement is seen in approximately 50% of patients D. Tends to affect younger patients Answer: B. Increased prevalence in western counties as compared to Asians Explanation:  Important points about Takayasu- 1) Takayasu arteritis has strong female predominance (F:M=9:1) 2) Increased prevalence in Asian populations 3) Tends to affect younger patients ( less than 50 years of age) 4) Pulmonary artery involvement is seen in 50% of patients 5) Takayasu was an ophthalmologist

Q. Most common cause of tricuspid regurgitation is? A. Rheumatic heart disease B. Infective endocarditis C. Ebstein's anomaly D. Functional Answer: D. Functional Explanation: Functional TR due to right ventricular dilatation is most common cause of TR. RV dilatation commonly coexists with left sided cardiac pathologies.

Q. True regarding Fontan surgery? A. Bidirectional glenn shunt is usually done within 1 week of birth B. PA banding may be required in patients with significant pulmonary stenosis prior to glenn surgery C. Fenestration decreases post-op pleural effusion D. Peri-operative mortality is around 20% Answer: C. Fenestration decreased post-op pleural effusion Explanation: Fontan surgery is type of single ventricular repair required for some complex congenital heart diseases. It is a multistaged procedure. Also known as Total cavopulmonary connection (TCPC). It separates systemic and pulmonary circulation. 1 st stage procedure is done to normalize pulmonary blood flow (BT shunt in case of decreased pulmonary blood flow situations like PS and PA band in case of increased pulmonary blood flow situations). 2 nd stage is called bidirectional glenn shunt (BDG) or Hemifontan which is done at the age of 4-6 months and final stage is completion of Fontan Advantages:

Q. What is false regarding Fontan circuit? A. Fenestration improves cardiac output and reduces congestion B. Fenestration decreases systemic saturation C. Plastic bronchitis is rare but known complication D. Protein losing enteropathy does not improve after cardiac transplantation Answer: D. Protein losing enteropathy does not improve after cardiac transplantation Explanation:  Fontan procedure

Q. Which of the following is false about Fontan surgery? A. Systemic and pulmonary circulation are separated B. It is a type of univentricular repair C. It is done when PVRI is more than 6 woods units/m 2 D. Ten years survival is 80-85% Answer: C. It is done when PVRI is more than 6 woods units/m2 Explanation:  Fontan procedure

Pulmonary hypertension Pulmonary arterial hypertension is restricted to those with a hemodynamic profile in which high pulmonary pressure is a  result of elevated precapillary pulmonary resistance and normal pulmonary venous pressure which is measured as a pulmonary wedge pressure of 15 mmHg or less. Definition: Resting mean pulmonary artery pressure of 25 mm Hg or more at catheterization of right heart. This is the hemodynamic feature which is shared by all types of pulmonary hypertension in Dana point classification system. CLASSIFICATION OF PULMONARY HYPERTENSION Pulmonary hypertension resulting from heart disease (group 2) implies an increase in pulmonary arterial pressure due to backward transmission of pressure elevation. Precapillary pulmonary hypertension such as that resulting from lung disease is group 3. Chronic thromboembolic pulmonary hypertension is group 4. Disease resulting from multifactorial mechanisms is group 5. Important point to no

Shone complex -Shone complex is a rare combination of subvalvular aortic stenosis, supravalvular mitral membrane, parachute mitral valve, and coarctation of aorta. -A parachute mitral valve occurs when all the chordae arise from a single, fused papillary muscle. -This abnormality is associated with mitral stenosis of various degrees and with Shone syndrome.

Q. What is the life expectancy of a person with aortic stenosis presenting with history of syncope? A. 1 year B. 5 years C. 8 years D. 3 years Answer: D. 3 years Explanation:  Life expectancy of a person with symptomatic severe stenosis: (Mnemonic- A. S. D.) A- Angina- 5 years S- Syncope- 3 years D- Dyspnea (Heart failure)- 2 years

DEEP VEIN THROMBOSIS   (DVT)- Definitions Unprovoked deep vein thrombosis implies that no identifiable provoking environmental event for DVT is evident. Proximal DVT is one that is located in the popliteal, femoral, or iliac veins. Isolated distal DVT has no proximal component, is located below the knee, and is confined to the calf veins (peroneal, posterior, anterior tibial, and muscular veins). TREATMENT -  (1) MEDICAL Anticoagulation is the mainstay of therapy. Acute symptomatic proximal DVT - anticoagulation (Grade 1B), provided the risk of bleeding is not high. Asymptomatic proximal DVT - anticoagulation Symptomatic isolated distal DVT - anticoagulation For select patients with isolated distal DVT (eg, those at high risk of bleeding, negative D-dimer level, asymptomatic or minor symptoms, without risk factors for extension, and/or minor thrombosis of the muscular veins), surveillance with serial ultrasound over a two-week period rather than anticoagulat

Q. Brockenbrough needle is used for? A. Tricuspid valve commissurotomy B. Interatrial septal puncture C. Interventricular septal puncture D. Pulmonary valvotomy Answer: B. Interatrial septal puncture Explanation: Percutaneous mitral valve commissurotomy (PTMC) is required in severe symptomatic noncalcific mitral stenosis. It should be done after ruling out LA/LAA thrombus. For PTMC, right atrium is entered through IVC from right remoral venous access. To reach the left atrium from right atrium, interatrial septum has to punctured at fossa ovalis which is done with the help of Brockenbrough needle . After that Inoue balloon is inflated at level of mitral valve to improve mitral stenosis. 

There are three possible arrangements: Solitus (normal) Inversus (mirror image of normal), and Ambiguous (not clearly solitus or inversus ). Here the thoracic and abdominal organs cannot be lateralized and have neither the normal nor mirror image arrangement. CARDIAC ORIENTATION- Relationship or axis of the base to the apex of the heart Levocardia is defined as a normal cardiac position with the cardiac base-to-apex axis pointing from upper right to lower left. Dextrocardia refers to a heart with the base-to-apex axis pointing from the upper left to the lower right. Mesocardia refers to a heart that is usually in the midline with the base-to-apex axis directly from superior to inferior. So, the normal arrangement is Situs Solitus with Levocardia And the mirror image of it is called Situs Inversus with Dextrocardia LAST 3 POINTS ( most important ones actually ) 1) The normal arrangement is Situs Solitus with Levocardia And the mirror image

Q. All of the following predict non-operability in acyanotic congenital heart diseases with increased pulmonary artery pressure except? A. Baseline saturation less than 92% B. PVRI/SVRI >0.3 C. PVRI > 6 woods units/m 2 D. Qp/Qs > 2.0 Answer: D. Qp/Qs > 2.0 Explanation: In acyanotic congenital heart diseases (ASD, VSD, PDA, Complete AVSD) with pulmonary artery hypertension, there is a great dilemma for complete repair of the defect. Because if the patient has developed Eisenmenger syndrome, then he will have a poorer prognosis after surgery. Baseline saturation of less than 92% suggests significant reversal of shunt due to increased PA pressure. During cardiac catheterization study, pulmonary vascular resistance index (PVRI) more than 6 W/m2 and PVRI/SVRI more than 0.3 suggest significantly raised pulmonary artery pressure. These patients might not do well after surgical closure of the defect. For further decision regarding surgery in these cases, vasod

ISOMERISM - The term “isomerism” has been used to describe the combination of atrial situs ambiguity (heterotaxy) and visceral heterotaxy.

Left ventricular aneurysm represents an outpouching containing endocardium, epicardium and thinned, abnormally contracting and scarred myocardium which shows characteristic constant functional wall motion abnormality, usually dyskinesia. Left ventricular pseudoaneurysm is the result of rupture of the ventricular free wall but contained by the overlying adherent pericardium or scar tissue.

It refers to an extra mogul or bump along the upper left cardiac silhouette just below the left main bronchus in CXR. CAUSES in order of importance:- 1-enlargement of LA Appendage 2-Partial pericardial defect 3-Right ventricular outflow tract dilatation as in Ebstein, EMF, Post TOF repair 4-Asymmetric septal hypertrophy 5-Pericardial hydatid 6-LV aneurysm (mycotic which usually involves the free wall) 7-Coronary artery aneurysm

Q. In left dominant circulation, which of the following is not a branch of left circumflex artery? A. AV nodal artery B. Obtuse marginal artery C. Posterolateral branches D. Conus artery Answer: D. Conus artery Explanation: In right dominant circulation, AV nodal and posterolateral branches arise from RCA whereas in left dominant circulation they arise from left circumflex artery. In codominant circulation, AV nodal artery arise from RCA and posterolateral branches arise LCx. Obtuse marginal arteries are branches of left circumflex and acute marginal arteries are branches of right coronary artery. Origin of conus artery is not affected by dominance of cardiac circulation. It arises from RCA and supplies the right ventricular outflow tract. Sometimes, it may directly arise from left main coronary artery.

Q. Which of the following drug may be stopped in asymptomatic patients with low left ventricular ejection fraction? A. Beta blocker B. ACE inhibitor C. Diuretic D. All of them should be stopped unless patient is symptomatic Answer: C. Diuretic Explanation: Beta blockers and ACE inhibitors are used in CHF because they have suvival benefit. Both of these are class I recommendation in patients with heart failure with reduced ejection fraction (HFrEF). Whereas, Diuretics are used only for symptomatic benefit. So, if the patient is asymptomatic but having low ejection fraction, beta blockers and ACE inhibitors should be continued and diuretics are given according to symtoms of the patient. 

Rare congenital defect in the fusion of anterior chest wall resulting in heart being located partially or totally outside thoracic cavity Locations- Adjacent to thorax 60 percent Abdominal 15-30 percent Thoraco abdominal 7-18 percent Cervical 3 percent

MINOCA -Myocardial Infarction With Non Obstructive Coronary Arteries MINOCA is clinically defined by the presence of 1-Acute MI criteria 2-Absence of obstructive coronary artery disease (less than 50 percent stenosis, if any, of the epicardial coronary arteries) 3-No other cause for the clinical presentation at the time of angiography e.g. takotsubo cardiomyopathy

MAJOR 1) Dilatation of ascending aorta, with or without AR, involving at least the sinuses of valsalva 2) Dissection of the descending aorta MINOR 1) Dilatation or dissection of the descending thoracic or abdominal aorta before 50 years of age 2) Dilatation of the MPA before 40 years of age 3) Mitral valve prolapse with or without MR 4) Calcification of the mitral annulus before 40 years of age

Q. True about Kawasaki disease? A. Thrombocytopenia is a common finding B. Harada score is used for diagnosis of Kawasaki C. Coronary aneurysms usually develop after 1 st 10 days of illness D. Vesicular eruptions are usually seen on hands and trunk of the patient Answer: C. Coronary aneurysms usually develop after 1 st 10 days of illness Explanation: Harada score is used in Kawasaki for prediction of developing coronary artery aneurysm which usually develop after 10 days of illness. Thrombocytosis is usually seen in Kawasaki disease and thrombocytopenia suggests viral illness. Two types of skin lesion are never seen in Kawasaki disease: 1. Vesicular lesions and 2. Bullous skin lesions

Q. Which of the following is true regarding therapy in ACS? A. Oxygen should be given to all patients B. Nitrates can be used safely in RV MI C. Oral beta blockers are recommended in all ACS patients unless contraindicated D. Calcium channel blockers are absolutely contraindicated in ACS Answer: C. Oral beta blockers are recommended in all ACS patients unless contraindicated

Q . Which of the following is true about NSTEMI? A. Normal ECG (electrocardiogram) does not rule out ACS. B. Patients with normal or abnormal ECG have same prognosis C. >0.2 mV ST depression should be present for diagnosis D. All are correct Ans : A. Normal ECG (electrocardiogram) does not rule out ACS. Explanation Normal ECG (electrocardiogram) carries a favorable prognosis but does not rule out ACS. Nearly 50 % of patients presenting with UA (unstable angina)/NSTEMI (non ST-elevation myocardial infarction) have a normal or unchanged ECG. UA/NSTEMI : New T wave inversions >0.2 mV and ≥ 0.05 mV ST depressions are suggestive.

Q. Most common cause of tachycardia induced cardiomyopathy is? A. Atrial flutter B. Atrial fibrillation C. Ventricular tachycardia D. Ventricular fibrillation Answer: B Explanation: Tachycardia induced cardiomyopathy (TIC) is defined as systolic and/or diastolic ventricular dysfunction resulting from a prolonged elevated heart rate which is reversible upon control of the arrhythmia or the heart rate. It is a rate dependent cardiomyopathy and those patients with higher tachycardia rates develop TIC earlier. Abnormal calcium handling, reduced cellular energy storing, and abnormal energy use have been proposed as the underlying mechanisms responsible for this syndrome. Pathologic changes start as early as 24-48 hours after onset of tachyarrhythmia in experimental models. Most common cause is supraventricular tachycardia and of them most common sustained tachycardia is atrial fibrillation.

Q. Most common arrhythmia in Holiday heart syndrome is? A. Atrial flutter B. Atrial fibrillation C. Ventricular tachycardia D. Ventricular fibrillation Ans: B Explanation: Holiday heart syndrome is defined as an acute cardiac rhythm and/or conduction disturbance, most commonly supraventricular tachyarrhythmia in the form of atrial fibrillation, associated with heavy ethanol consumption in a person without other clinical evidence of heart disease. Typically, this resolves rapidly with spontaneous recovery during subsequent abstinence from alcohol use.

Q. Most common cardiac mechanism for sudden cardiac death is? A. Ventricular tachycardia B. Ventricular fibrillation C. Asystole D. Bradyarrhythmias Answer: B Ventricular fibrillation is most common mechanism for sudden cardiac deaths.

Q. Most common cause of sudden cardiac death in young athletes is? A. Hypertrophic obstructive cardiomyopathy B. Myocardial infarction C. Coronary artery anomalies D. Myocarditis Answer: Option A Explanation: Most common cause of sudden cardiac death in young patients (less than 35 years) is HOCM followed by coronary artery anomalies. Whereas, most common cause of SCD in old patients is coronary artery disease and myocardial infarction.

Q. Total electrical alternans is seen in ? A. Large pericardial effusion B. Pulmonary embolism C. Congestive heart failure D. Myocardial infarction Answer: A  Explanation: Electric alternans is seen in cardiac tamponade or massive pericardial effusion. It occurs due to swinging motion of heart in a large sac of fluid (Pericardial fluid).  Electrical alternans must be distinguished from mechanical alternans (eg, pulsus alternans), although both may coexist. Pulsus altenans is most commonly seen in severe left ventricular systolic impairment and is suggestive of grim prognosis for the patient.

Q. Prominent U wave in ECG are seen in? A. Hyperthermia B. Hyperkalemia C. Hypokalemia D. Hypercalcemia Answer: Option C Explanation: Prominent U waves are most commonly seen in hypokalemia and hypothermia. The mechanism of appearance of these waves is not known. The two theories state that U waves occur due to: 1) Delayed repolarization of Purkinje fibres 2) Prolonged repolarization of mid myocardial M cells.

Q. El-Sherif sign is? A. rSR complex in lateral chest leads B. Persistent ST elevation in anterior leads in myocardial infarction C. PR prolongation in acute rheumatic fever D. Delta wave in WPW syndrome Answer: A Explanation: A characteristic rsR′ pattern or its variants (rSr′ or rSR′) with normal or prolonged QRS duration in left surface leads including the apex lead and the orthogonal scalar X lead may be seen in patients with coronary heart disease and left ventricular aneurysm. This was first described by El-Sherif in 1970 hence known as El-Sherif sign. Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC487350/

Q. El-Sherif sign in ECG is seen in presence of ? A. Left ventricular aneurysm B. Acute myocarditis C. Acute pericarditis D. Acute rheumatic fever Answer: Option A Explanation: El-Sherif sign

Q. Eisenmenger’s physiology will result from an unoperated: a. Small atrial septal defect b. Tetralogy of Fallot c. Large patent ductus arteriosus d. Coarctation of the aorta e. Pulmonary stenosis Answer: Option c Explanation: Large left to right shunts (e.g. Large PDA, VSD, ASD) lead to excessive pulmonary blood flow and irreversible changes in pulmonary capillaries which cause pulmonary arterial hypertension and ultimately reversal of cardiac shunt. Small left to right shunts usually don’t cause Eisenmenger’s syndrome. TOF and PS have decreased pulmonary blood flow and COA is a left sided obstructive lesion which do not cause Eisenmenger’s syndrome.

Q. Gorlin’s formula requires all of the following to calculate aortic valve area in aortic stenosis patient except? a. Cardiac output b. Pulmonary capillary wedge pressure c. Heart rate d. Systolic ejection period Answer: Option b Gorlin's formula to calculate aortic valve area Aortic valve area= CO / {SEP x HR x 44.3(MG) 1/2 } Where, CO= Cardiac output SEP= Systolic ejection period HR= Heart rate MG= Mean pressure gradient Simplified Hakki’s formu la for calculation of aortic valve area Aortic valve area= CO / (MG) 1/2 Where, CO= Cardiac output MG= Mean pressure gradient Note: Peak gradient can also be used in place of mean gradient in case of Hakki's equation.

Q.  A young man in late his late 20s, case of rheumatic heart disease has a blood  pressure of 160/70 on examination. His mean arterial pressure  is: a. 100 mm Hg b. 110 mm Hg c. 90 mm Hg d. 120 mm Hg e. Can not be determined without knowing the heart rate Answer: Option a  Mean arterial pressure= (Systolic blood pressure + 2 x Diastolic blood pressure)/ 3