Learning Cardiology

Q. Which of the following risk factor is responsible for most attributable deaths worldwide? A . Smoking B . Hypertension C . Diabetes melllitus D . Hyperlipidemia Answer: B. Hypertension Explanation: Hypertension accounts for more attributable deaths worldwide than any other risk factor, whereas smoking and hyperlipidemia are second and third, respectively. Additional risk factors in a patient have cumulative effect and increase risk of mortality.

Q. A 60-year-old man with no previous symptoms had a routine ECG. The ECG shows left bundle branch block. The patient is currently taking Aspirin 75 mg od. He has a family history of myocardial infarction. He smokes 20 cigarettes a day. The GP is concerned and refers the patient for further investigation. On examination, BP is 120/70 mmHg and there are no findings during cardiovascular examination.  Which of the following investigations is indicated? A.  Exercise ECG B.  CT of coronary arteries C.  Myocardial perfusion imaging D.  Coronary angiography    Answer: C. Myocardial perfusion imaging Explanation: For a patient with moderate likelihood of CAD (this patient is not symptomatic so is not in the high-risk category) non-invasive testing such as Exercise tolerance tests or myocardial perfusion tests should be performed. An exercise ECG test (TMT) will be difficult to interpret in this case due to the ECG changes of LBBB. Thus its most  appropriate to conduct a myocardial

Q. A trial assessed a statin tablet compared to placebo for stroke prevention over 1 year. There were 10% of patients developing stroke in the group taking a tablet and 20% in the carotid endarterectomy group developing a stroke over the 1 year. What is the number needed to treat over 1 year to prevent 1 death?    Options: A. 1 B.  10 C. 10 0 D. 1000 Answer: B. 10 Explanation: Number needed to treat (NNT) is defined as number of patients being given treatment for prevention of one death. Number need to treat: 1/Absolute risk reduction Stroke in patients taking tablet: 10%= 0.1 Stroke in patients undergoing endarterectomy: 20%= 0.2 Absolute risk reduction: 0.2-0.1= 0.1 So, Number needed to treat to save one life: 1/0.1= 10  

Q. Lipidic cells are characteristic of which cardiac tumor? A. Papillary fibroelastomatosis B. Atrial myxoma C. Fibrosarcoma D. Rhabdomyoma  Answer: B. Atrial myxoma Atrial myxoma: Most common benign cardiac tumour. Most commonly seen in left atrium. May be associated with Carney's complex. Lipidic cells are characteristic of atrial myxoma.

Q. Myocardial infarction in case of aortic dissections most commonly involve? A. LAD territory B. RCA territory C. LCx territory D. Ramus intermedius territory Answer: B. RCA territory Explanation:  Aortic dissections when extending to aortic root, may involve coronary arteries and cause myocardial infarction. Most commonly involved coronary artery in aortic dissections is right coronary artery.

Q. Calcium sign is seen in? A. Aortic aneurysm B. Aortic dissection C. Rheumatic heart disease D. Constrictive pericarditis Answer: B. Aortic dissection Explanation: The calcium sign is defined as the separation of the intimal calcification from the outer aortic soft tissue border by more than 10 mm . It is a specific chest radiographic finding of aortic dissection. It is more commonly seen in descending aortic dissection than aortic arch dissections.

Q.  A patient with atrial fibrillation was prescribed  digoxin.  What does it bind to in order to generate its  mode of action? A. Calcium channel B. Potassium channel C.  Na-Ca transporter D. Na / K- ATPase   Answer: D.    Na / K- ATPase   Explanation:  Digoxin belongs to cardiac glycoside group of medications. It is obtained from foxglove plant. Half life is 36 hours . Mechanism of action: Inhibition of Na/K ATPase and ultimately increased intracellular calcium. Eliminated mainly by renal excretion through P-glycoproteins . Narrow therapeutic index. Can cause gynecomastia . Effective plasma level between 0.5 to 1.0 ng/ml .

Q. Litten's sign is seen in? A. Rheumatic heart disease B. SLE C. Infective endocarditis D. Aortic regurgitation Answer: C. Infective endocarditis Explanation:  In infective endocarditis , white centred hemorrhages (cotton wool spots) can be seen in the retina on the fundoscopic examination of the patients. These are called as roth spots and sign is known as Litten's sign. 

Q. Batista procedure is used for? A. Ebstein's anomaly B. DCMP C. HOCM D. Tricuspid atresia Answer: B. DCMP Explanation: Batista procedure is also called as left ventricular reduction surgery . It is used in dilated cardiomyopathy and is supposed to improve geometric remodeling. Initial reports showed promising results. However, this method was found to be of very little benefit. Hence it is no longer considered a recommended treatment for this disease. 

Q. Which of the following is not a major criteria for congestive heart failure? A. Hepatojugular reflex B. PND attacks C. S3 gallop D. Tachycardia (Heart rate more than 120/minute) Answer: D. Tachycardia (Heart rate more than 120/minute) Explanation:  Framingham proposed the diagnostic criteria for congestive heart failure. Either 2 major or one major and 2 minor criterias should be fulfilled for the diagnosis of CHF Major criterias are: Paroxysmal nocturnal dyspnea Weight loss of 4.5 kg in 5 days in response to treatment Neck vein distention Rales Acute pulmonary edema Hepatojugular reflux S  3  gallop Central venous pressure >16 cm water Circulation time of ≥25 seconds Radiographic cardiomegaly Pulmonary edema, visceral congestion, or cardiomegaly at autopsy And minor criterias are: Nocturnal cough Dyspnea on ordinary exertion A decrease in vital capacity by one third the maximal value recorded Pleural effusion T

Q. Prevalence of hypertrophic cardiomyopathy in general populations is? A. 1 in 5000  B. 1 in 500 C. 1 in 1000 D. 1 in 100 Answer: B. 1 in 500

NORMAL CARDIAC ANATOMY The anterior mitral leaflet is in fibrous continuity with the aortic valve and fibrous skeleton. The posterior leaflet is attached to the pliant endocardium instead of rigid fibrous skeleton. For this reason, annular dilatation, a cause of MR, has a greater effect on posterior leaflet function than on anterior leaflet function Figure 1: Dark chambers in the image are RA and RV, Bright chambers are LA and LV,  Black arrow is left ventricular outflow tract. Figure shows continuity between anterior mitral leaflet ( white arrow ) and left ventricular outflow tract leading to aorta SUBMITRAL LEFT VENTRICULAR ANEURYSM   1. Congenital origin or predisposition 2. Junctional defect between cardiac muscle  and fibrous structure of heart 3. Can extend behind LA, LV 4. Aneurysmal growth causes mitral apparatus distortion and can lead to MR and cardiac failure 5. Should be suspected with embolism and ventricular arrhythmias and absence of

The reported incidence of femoral artery pseudoaneurysms varies widely in the literature, with some society guidelines expecting an acceptable rate of less than 0.2%.  Management:  Size less than 3 cm - Follow up with serial duplex till spontaneous thrombosis Size more than 3 cm or more than 1 cm with expected poor compliance, pain or growth during follow up - DGTI ( duplex guided thrombin injection ) Size less than 1 cm which fails to resolve at 6 weeks or associated with arteriovenous fistula - DGC ( duplex guided compression )

Q. Advantages of choosing left radial artery over right radial artery during trans-radial PCI are all except? A. Prevalence of subclavian artery tortuosity and radial artery loops are three times more common in right radial artery B. Hooking of LIMA is easier from left radial artery C. Learning curve is short in left radial route than right D. Incidence of radial artery spasms is more in right radial artery Answer: D. Incidence of radial artery spasms is more in right radial artery Explanation: PCI from left radial route has many advantages as compared to right artery. Prevalence of radial artery loops and subclavian artery tortuosity are more three times more common on right side. Learning curve is longer in right radial artery and hooking of left internal mammary artery (after CABG) is difficult from the right radial route because it involves crossing to the opposite side from the aortic arch. However, the incidence of radial artery spasms during the procedure is

Q. Most common malignant primary cardiac tumor in infants and children? A. Lymphoma B. Angiomyosarcoma C. Rhabdomyosarcoma D. Teratoma Answer: C. Rhabdomyosarcoma Explanation:  Cardiac tumors

Q. Most common malignant primary cardiac tumor in adults? A. Rhabdomyosarcoma B. Leiomyosarcoma C. Angiosarcoma D. Lymphoma Answer: C. Angiosarcoma Explanation:  Cardiac tumors

Q. Most common primary cardiac tumor in infants? A. Myxoma B. Lymphoma C. Rhabdomyoma D. Fibroma Answer: Rhabdomyoma Explanation:  Cardiac tumors

Q. Most common primary cardiac tumor at the age of 60 years? A. Angiosarcoma B. Rhabdomyoma C. Myxoma D. Lymphoma Answer: C. Myxoma Explanation:  Cardiac tumors

Q. Most common cardiac tumor at the age of 60 years? A. Lymphoma B. Myxoma C. Secondary D. Angiosarcoma Answer: C. Secondary Explanation: Most common cardiac tumor at any age: Secondary i.e. metastasis Most common primary cardiac tumor in adults: Myxoma 2 nd most common primary cardiac tumor in adults: Fibroma Most common primary cardiac tumor in infants and children: Rhabdomyoma Most common malignant primary cardiac tumor in adults: Angiosarcoma Most common malignant primary cardiac tumor in infants and children: Rhabdomyosarcoma *Remember most common cardiac mass is thrombus.

Q. A 65-year-old comes to the clinic for a review of his symptoms. He has been following up for aortic stenosis for the last 10 years. Over the past three months he has been complaining of fatigue and has lost 8 kg in weight. A full blood count was requested: Hb 9.2 g/dl    MCV 65 fl Plt 360 x 10 9 /l WBC 5.0 x10 9 /l Blood film Hypochromic, microcytic picture. An upper GI endoscopy and duodenal biopsy was normal.  What is the most appropriate next investigation? A- Transthoracic echocardiogram B- Bone marrow biopsy C- Colonoscopy D- Faecal occult blood E- Mesenteric angiography    Answer: C. Colonoscopy Explanation: Patient might be having GI angiodysplasia which can be seen in association with aortic stenosis. This syndrome is known as Heyde's syndrome.  Patient presents with anemia due to chronic blood loss. UGI endoscopy is usually normal. Colonoscopy should be next investigation in this case. Definitive treatment is surgical replacement of aortic va

Q. A 25 years old gentleman is brought to emergency with the complaint of fever for 7 days. He drinks five units of alcohol per day and admitted to regular intravenous drug abuse. On examination, he is febrile, has tachypnea and tachycardia. Blood pressure is 108/70. JVP is elevated and there is a murmur all over the precordium. What will be most likely cause of infection in this patient? A. Staphylococcus epidermidis B. Streptococcus viridans C. Staphylococcus aureus D. Pneumocystis carinii Answer: Staphylococcus aureus Explanation: With given history and abuse of i/v drugs, tricuspid valve endocarditis is most likely diagnosis. Among, i/v drug abusers, Staphylococcus aureus is most common cause. 

Q. Branham's sign is seen in? A. Anemia B. Arteriovenous fistula C. Hyperthyroidism D. Beri-beri Answer: Arteriovenous fistula Explanation:  It is also known as Nicoladoni-Branham's sign. Seen in systemic AV fistula Occurs when compression is applied just proximal to AV fistula, there is reflex bradycardia due to increase in peripheral vascular resistance and afterload.

SEGMENTAL ARTERIAL MEDIOLYSIS - Rare, non arteriosclerotic, non inflammatory vascular disease of unknown origin - Involves visceral arteries of abdomen - Any vessel may be involved with skip pattern - No predilection for bifurcation - Dilatations, saccular aneurysms, dissecting aneurysms, stenosis, thrombosis/occlusion

FIBROMUSCULAR DYSPLASIA  - Idiopathic, segmentary, non inflammatory, non atherosclerotic - All layers of small and medium sized arteries involved - 4-6% prevalence in renal arteries and 0.3-3% in cervico-encephalic arteries - In more than half the cases, lesions are bilateral - Branch or bifurcation involvement also seen -Multifocal string of beads lesions seen in 84% of the cases -Almost any artery can be involved including mesenteric, brachial and iliac

MYCOTIC ANEURYSMS -Term coined by Osler to describe aneurysms associated with bacterial endocarditis -Emboli occludes vasa vasorum or vessel lumen causing vascular wall infection -Embolism occurs in 25-50% of patients but only 1-5% develop symptomatic mycotic aneurysms -Most commonly seen in the intracranial arteries , followed by visceral arteries and upper or lower  extremely -Typically involve bifurcation

vEDS: - Group of clinically and genetically heterogeneous disorders - Also known as Type IV EDS - Prevalence 1 in 250000 - Autosomal dominant - Mutation in COL3A1 - type III collagen alpha chain 1 - Characterised by aneurysm, dissection or rupture of medium-sized abdominal arteries and abdominal aorta - No predisposition for aortic root involvement - most patients will have one complication by the age of 40 years

Q. Most common complication during percutaneous intervention of coronary arteries is? A. Pericardial effusion B. Vascular complication C. Stent thrombosis D. Arrhythmias Answer: B. Vascular complication

Q. A patient has been provided with a single chamber pacemaker recently for complete heart block. The pacing mode is set as VVIR. R in VVIR stands for? A. Rate responsive B. Rate controlled C. Rate sensitive D. Rate inhibition Answer: A. Rate responsive Explanation: 1st letter: Chamber paced 2nd letter: Chamber sensed 3rd letter: Action of the pacemaker after sensing a beat 4th letter: Rate responsiveness i.e. demand ventricular pacing is present with response to exercise VVIR means: Ventricle is paced, ventricle is sensed, pacing is inhibited if beat is sensed and rate responsiveness is present in pacemaker i.e. rate of pacing is increased if a physiological need is there e.g. during exercise.

Q. All of the following are relative contraindications of mechanical prosthetic valve except? A. Long expected lifetime B. Unreliable anticoagution therapy C. Pregnancy D. Previous thormbosed valve Answer: A. Long expected lifetime Explanation: Long expected lifetime is an indication for mechanical prosthetic valve as bioprosthetic valve gets degenerated in 10-15 years. Mechanical prosthetic valves have a high risk of valve thrombosis and hence require lifelong anticoagulation. Anticoagulation becomes problematic in pregnancy. And, previous history of valve thrombosis increases the risk of recurrent valve thrombosis.