Learning Cardiology

Q. Which of the following is incorrect regarding prevention of contrast induced nephropathy? A. Preprocedure hydration with 0.9% NaCl is better than 0.45% NaCl B. Low osmolar contrast media is better than iso-osmolar contrast media C. Preprocedure use of N-acetyl cysteine is not recommended D. Biplane angiography is useful in reducing the dose of contrast Answer: B. Low osmolar contrast media is better than iso-osmolar contrast media Explanation: Contrast induced nephropathy (CIN) Transient increase in creatinine by 0.5 mg/dl or 25% increase from baseline. Occurs in 5% of patients following cardiac angiography. It is non-oliguric, peak within 1 to 2 days and then return to baseline by 7 days but may rarely require chronic dialysis. Risk factors: DM Pre-existing renal dysfunction Multiple myeloma Volume depletion Other nephrotoxic drug therapy The recommended maximum dose of contrast to limit CIN is 3 ml/kg (or 5 ml/kg divided by S. creatin

Q. Which of the following agent is not used for treatment of coronary no-reflow? A. Nicardipine B. Adenosine C. Nitroglycerine D. Verapamil E. Nitroprusside Answer: C. Nitroglycerine Explanation: The intracoronary agents used for treatment of coronary no-reflow include- A. Adenosine (For RCA 18-24 mcg, LCA 24-36 mcg) B. Sodium nitroprusside (100 mcg) C. Nicardipine (200 mcg) D. Diltiazem (1 mg) E. Verapamil (100-200 mcg) Adenosine can also be given by intravenous route in 140-180 mcg/kg/min dose. Nitroglycerin is used for treatment of coronary vasospasm. It is primarily an epicardial vasodilator, and should not be used in situations like no-reflow where small vessel (arteriolar) dilation is required.

Q. Warden’s procedure is used for? A. Sinus venosus type of ASD B. Ostium secundum ASD C. Ostium primum ASD D. Coronary sinus type ASD Answer: A. Sinus venosus type of ASD Explanation: Partial anomalous pulmonary venous connection (PAPVC) is characterized by the failure of 1-3 pulmonary veins to incorporate within the developing left atrium. Most commonly right upper pulmonary vein is affected and connects to the superior vena cava. Sinus venosus ASD is typically associated with PAPVC. Warden’s procedure is used for correction of partial anomalous pulmonary venous connection (PAPVC) to prevent the stenosis of pulmonary veins or vena cava.

Q. Most common cardiovascular abnormality in Turner syndrome is? A. Coarctation B. Aortic valve disease C. Hypertension D. ASD Answer: B. Aortic valve disease Explanation:  Turner syndrome is most common sex chromosome abnormality in females affecting 1:2000 live female births.  Webbed neck, broad chest, widely spaced nipples, and a low hairline. The most common presenting features are short stature and primary amenorrhea. Diabetes mellitus is also more common in Turner's syndrome. Most common cardiovascular abnormality in Turner's syndrome is Bicuspid aortic valve which is seen in 20-30% of patients. Other cardiovascular abnormalities include Coarctation of aorta (3-10%), hypertension and prolonged QT interval. Most common cause of death in Turner is Aortic aneurysm rupture.

Q. Which of the following is not true regarding perioperative management of a patient with implanted intracardiac device undergoing non-cardiac surgery? A. Pacemaker should be reprogrammed to asynchronous mode (VOO mode) B. Tachyarrhythmic therapy should be terminated in ICD C. Routine preoperative and postoperative interrogation of the device is not required D. Bipolar electrocautery should be preferably used Answer: C.   Routine preoperative and postoperative interrogation of the device is not required Explanation:  Patients with Implantable cardioverter defibrillators (ICD) and pacemakers undergoing surgery: Electrocautery may interfere with devices, leading to: Device reset to default mode (Power on Reset events) which can cause asynchronous to inhibited pacing and it may be life threatening to the patient if he is pacemaker dependent Inhibition of pacemaker output False sensing with increased pacemaker rate ICD firing Myocardial injury with

Q. For the patients with implanted cardiac devices undergoing non-cardiac surgery, which of the following is not correct? A. Electrocautery may reset device to default mode B. May cause inhibition of pacemaker output C. Inappropriate ICD firing D. Power on reset events do not pose any threat to the patient Answer:  D. Power on reset events do not pose any threat to the patient Explanation:  Implantable cardiac devices

CORONARY OSTIAL STENOSIS AND ATRESIA (COSA) COSA is a rare congenital coronary anomaly which affects the left coronary artery more frequently than the right coronary artery.    The aortic ostium in a case of COSA can be in the normal location or at an ectopic site. Atresia of the left main coronary artery is characterised by the congenital absence of the left main coronary ostium and left main trunk with normally connected left anterior descending and circumflex arteries which proximally end blindly.   These patients are able to survive via congenitally developed collateral circulation from either the conus branch artery (Vieussens’ anastomotic ring) or through the right coronary artery (retroaortic Kugel’s ring),  anterior ventricular branches of the right coronary artery or  through the terminal ramifications of the posterior descending branch with retrograde flow to the terminal branch of the left anterior descending artery at the apex of the left ventricle.   

Q. Which one of following echocardiographic features is an important risk factor for sudden cardiac death in HOCM? A.  Gradient of 30 mmHg across left ventricular outflow tract B.  Septal wall thickness of > 3 cm C.  Systolic anterior motion of mitral valve D.  The presence of severe mitral regurgitation    Answer: B. Septal wall thickness of >3 cm Explanation:  Most common cause of SCD in young adults during physical activity and overall also is HOCM. To prevent SCD, Implantable cardioverter defibrillator (ICD) therapy is recommended in patients with  1. Prior cardiac arrest (Class I) 2. Sustained ventricular tachycardia (VT) (Class I)  3. History of SCD in a first-degree relative (Class IIa) 4. Marked LV hypertrophy (Septal thickness more than 3 cm) (Class IIa) 5. Recent unexplained syncope (Class IIa)  6. Nonsustained VT or an abnormal blood-pressure response to exercise (Class IIa)

Frank sign-  Diagonal ear lobe crease (DELC) sign The Frank's sign is a diagonal crease in the earlobe that runs backward from the tragus at a 45-degree angle across the lobule to the rear edge of the auricle and may be a predictor of coronary artery disease. Frank sign is indicative of coronary artery disease (CAD). Frank's sign is thought to indicate premature aging and loss of dermal and vascular elastic fibers.  Although it has limited sensitivity, the sign is more useful diagnostically in persons younger than 60 years of age than in older persons. Sensitivity of 43% and specificity of 70% Pathophysiology: Microvascular disease of ear lobe which is end artery territory Grading system for severity of CAD                • Unilateral incomplete – least severe                • Unilateral complete                • Bilateral complete – most severe                Other classifications systems exist, but without the association with                       

Q. Which of the following is true about Brugada syndrome? A. AR inheritance B. Exertional syncope C. Functional phase 2 re-entry D. Female preponderance Answer: C. Functional phase 2 re-entry Explanation: Brugada syndrome: Cause of ventricular arrhythmia in structurally normal heart. Autosomal dominant genetic disorder. Loss of function genetic mutation in cardiac sodium channels (SCN5A and SCN10A). Functional phase 2 re-entry leads to ventricular arrhythmias in Brugada. ECG: Right bundle branch pattern with ST elevation in V1 to V3 leads. Types of Brugada syndrome (Image 1): Type 1: Coved type ST elevation (>/=2 mm) with inverted T waves Type 2:  Saddle-back ST-T wave configuration with an upright or biphasic T wave                                     Image 1: Types of Brugada syndrome  Brugada pattern ECG is more common in men as compared to women. Arrhythmic events more common during night and during sleep (Not during exe

Q. Ortner's syndrome occurs due to? A. Single ventricle with normally related great vessels B. Anomalous left coronary artery from pulmonary artery C. Dilated left atrium causing compression of trachea D. Enlarged pulmonary artery compressing recurrent laryngeal nerve Answer: D. Enlarged pulmonary artery compressing recurrent laryngeal nerve Explanation:  Ortner's syndrome is a rare condition and occurs because of compression of recurrent laryngeal nerve by cardiovascular structures. Most common cause is dilated left atrium due to severe MS. However, other causes include enlarged pulmonary artery, thoracic aortic aneurysms, aberrant subclavian artery which may cause compression of recurrent laryngeal nerve. Note: Ortner's syndrome does not occur due to compression of trachea.

Q. A 50 year old man presents with severe crushing chest pain radiating to left arm. His ECG showed dominant R waves in V1 and V2 leads. The T waves were upright and tall along with ST segment depressions.  Which artery is most likely to be occluded? A.  Right coronary artery B.  Septal branch of left anterior descending  artery C.  Circumflex artery D. Left main coronary artery Answer: C. Circumflex artery Explanation: The ECG changes are suggestive of posterior wall MI. Posterior myocardial infarction usually results from occlusion of the left circumflex coronary artery but the anatomy can vary a little. Occlusion of the right coronary artery may also result in a posterior MI. The changes of posterior myocardial infarction are seen indirectly in the anterior precordial leads. Leads V1 to V3 face the endocardial   surface of the posterior wall of the left ventricle. As these leads record from the opposite side of the heart instead of directly over the

Q. A 25-year old woman has presented to the clinic for assessment. She has a past medical history of palpitations and is suspected to have congenital long QT syndrome from evidence of her ECG findings. Which one of these drugs should be avoided? A. Amoxycillin B. Thyroxine C. Sertraline D. Paracetamol Answer: C - Sertraline Explanation: Common drugs which cause long QT syndrome are: Tricyclic antidepressants  ( e.g.sertraline) Antiarrhythmics: Quinidine Disopyramide Procainamide Amiodarone Sotalol Antipsychotics: Haloperidol and thioridazine Cisapride Antimalarials: Halofantrine Terfinadine

Q. A 66-year-old man presents with central chest pain radiating to the arm and the scapula. He has a history of hypertension and diabetes. He takes aspirin, gliclazide and metformin. On examination, he has absent pulses in the right arm and an irregularly irregular heartbeat. The blood pressure is 160/100 mmHg. He also complains of some left sided arm and leg weakness compared to the right. ECG showed significant ST elevation in leads II, III, aVf. His troponin I was 10 (normal less than 0.02). What should be next line of management? A. I/V thrombolysis B. Primary PCI for myocardial infarction C. CT aortography D. NCCT head Answer: C. CT aortography Explanation: The patient has chest pain mimicking the clinical history of myocardial infarction but has two other features (absent pulses unilaterally and hemiparesis) which could be manifestations of occlusion of vascular supply from the aorta. In aortic dissection, if the dissection flap occludes the bloo

Q. A 62-year-old man is seen in the cardiology OPD. During cardiac examination, it is noted that the pulmonary component of the second heart sound occurs before the aortic component. Which one of the following is associated with this finding? A) Pulmonary stenosis B) Left bundle branch block C) Right bundle branch block D) Atrial septal defect Answer: B- Left bundle branch block Explanation: This patient has reversed splitting of the second heart sound. Left bundle branch block causes a reversed split second heart sound as it results in a delay  in the aortic component. Other common causes of the reversed splitting of second heart sound are: Aortic stenosis RV pacing WPW syndrome (Type B)