Cardiology Quiz | Practice MCQ #mcq.ImBooz

• (A) Thin-capped fibroatheromas are most prone to cap disruption and thrombus formation
• (B) Fracture of the fibrous cap allows platelets, clotting factors, and inflammatory cells to come into contact with the thrombogenic necrotic lipid core, leading to thrombus
• (C) Disrupted plaques can be accurately identified by optical coherence tomography
• (D) Plaque rupture will always result in some degree of clinical ischaemia (ACS)

Check AnswerSolution[D]:- Clinically silent plaque rupture with spontaneous healing is well recognized. If a patient presents with an ACS , and a ruptured culprit plaque is identified without luminal stenosis (i.e. ongoing ischaemia), it is reasonable to continue medical therapy without stenting as long as the event has stabilized.

• (A) Clopidogrel, prasugrel, and ticagrelor all inhibit the same receptor (P2Y12 ADP receptor)
• (B) Clopidogrel and prasugrel are irreversible inhibitors, whereas ticagrelor is reversible
• (C) Clopidogrel and prasugrel are both prodrugs which are metabolized to the active form, whereas ticagrelor acts directly
• (D) All are converted to the active metabolite by the hepatic cytochrome enzyme (CYP3A4) Pathway

Check AnswerSolution[D]:- Clopidogrel and prasugrel are both pro-drugs, irreversible inhibitors, and once-daily regimes. The maintenance dose of prasugrel is halved for weight <60 kg or age>75 years. Clopidogrel is converted to its active metabolite by the cytochrome enzyme pathway; this accounts for the variability of action in some patients (hyporesponders) which can lead to stent thrombosis. Prasugrel is converted to its active form faster and more consistently. Ticagrelor is reversible and direct acting and therefore is again faster acting and more predictable than copidogrel. All inhibit the P2Y12 ADP platelet receptor.

• (A) This is likely to be a spurious result; continue with the current treatments but repeat the blood result urgently and watch for bleeding
• (B) This degree of platelet inhibition is to be expected with the current regime; reassure but watch for bleeding and repeat the bloods
• (C) This is a sign of early heparin-induced thrombocytopenia; stop the abciximab and replace platelets until >50 � 109/L
• (D) This may represent an immune-mediated thrombocytopenic reaction to abciximab; stop the infusion and repeat the bloods

Check AnswerSolution[D]:- Inadequate platelet inhibition or platelet replacement will increase the chances of early stent thrombosis and should be avoided. This clinical scenario suggests an early immune-mediated response to abciximab with thrombocytopenia. The platelet count should gradually recover on stopping the agent, but the platelets should not be replaced unless there were signs of significant bleeding. Heparin-induced thrombocytopenia usually occurs after a few days with repeated exposure. Pseudo-thrombocytopenia (clumping) is possible and would be obvious on a blood film, but this should be excluded rather than assumed.

• (A) A single administration of unfractionated heparin in this situation should be safe
• (B) Avoid all anticoagulants as a precaution and complete the procedure with Gb2b/3a cover
• (C) Bivalarudin is safe and effective in this situation
• (D) A single administration of fondaparinux in this situation should be safe and effective

Check AnswerSolution[C]:- Bivalarudin is a direct thrombin inhibitor and a safe alternative in a patient with previous heparin-induced thrombocytopenia (HIT). The Horizons-AMI trial suggested a significant reduction in all-cause mortality and major bleeding compared with the combination of UFH and GP2b/3a in primary angioplasty patients. Fondaparinux is a synthetic inhibitor of factor Xa and has been shown not to be inferior to LMWH in ACS, with halved major bleeding (OASIS-5 trial).

• (A) The left wrist would be the preferred route here
• (B) The right wrist would be the preferred route here
• (C) The left leg would be the preferred route, but you will need to obtain further information regarding the vascular procedures
• (D) The right leg would be the preferred route, but you will need to obtain further information regarding the vascular procedures

Check AnswerSolution[A]:- Although, based on the vascular procedure, it is often possible to access the femoral arteries, this is obviously best avoided as there is a greater risk of complications. The left radial will give direct access to the LIMA (comes off the left subclavian artery) and would be the route of choice. The right radial will not allow simple or safe access to the left subclavian artery. If the left radial has been harvested as a graft, then the femoral arteries may have to be considered.

• (A) Initial mortality of NSTE-ACS is higher
• (B) Six-month mortality of STEMI is higher
• (C) Long-term mortality of NSTE-ACS is higher
• (D) STEMI patients are older with more comorbity

Check AnswerSolution[C]:- NSTE-ACS is more frequent with older patients and more comorbidity. Mortality of NSTE-ACS is initially lower, but equal at 6 months and higher in the long term.

• (A) Add furosemide 40 mg od
• (B) R educe the bisoprolol
• (C) Further titrate the ramipril
• (D) Add Eplerenone 25 mg od

Check AnswerSolution[D]:- Aldosterone antagonists are indicated if EF ? 40% (EPHESUS trial) or if there is heart failure or diabetes, provided that there is no renal failure or hyperkalaemia. The diuretic action should help with the mild residual congestion. Blood pressure will appear to limit further titration of the ACE inhibitor at this stage.

• (A) Unfractionated heparin (GP 2b/3a)
• (B) Enoxaparin (GP 2b/3a)
• (C) Fondaparinux
• (D) Bivalarudin

Check AnswerSolution[C]:- Use of fondaparinux in the context of primary PCI was associated with potential harm in the OASIS-6 trial and therefore it is not recommended. Bivalarudin is probably the preferred choice currently in primary PCI, but all other options are reasonable. Intravenous enoxaparin is required initially in the context of primary angioplasty.

• (A) Call an anaesthetist to consider ventilation
• (B) Start a dopamine infusion
• (C) Give a fluid challenge
• (D) Start a nitrate infusion

Check AnswerSolution[B]:- This patient has moderate heart failure with pulmonary oedema and significant hypotension. The suggestion is that he may be developing cardiogenic shock. There is evidence of poor organ perfusion, reflected by the urine output, but his ventilation remains reasonable. Inotropic support is the next step. In a patient with BP < 90 mmHg dopamine (inotropic/vasopressor) should be considered. In patients with ‘adequate’ blood pressure (>90 mmHg) dobutamine (inotropic) or levosimendan (inotropic/vasodilator) may be preferable. Noradrenaline (vasopressor) may be preferable in cardiogenic shock or septicaemia.

• (A) Dual antiplatelets for 12 months and then aspirin long term
• (B) Ticagrelor for 1 month and aspirin long term
• (C) Aspirin for 1 month and ticagrelor long term
• (D) Ticagrelor alone is adequate long term

Check AnswerSolution[A]:- Current guidelines in the UK and Europe are 12 months dual-antiplatelet therapy (DAPT) after an acute coronary syndrome irrespective of the treatment or stent type. In elective angioplasty with a bare metal stent only 1 month of DAPT is required, followed by long-term aspirin as opposed to 12 months for drug-eluting stents (DESs). However, new-generation DESs with biocompatible or biodegradable polymers (the delivery agent for the drug) are showing safety with shorter durations, down to 3 months in some cases.

• (A) NYHA class II breathlessness
• (B) Aortic root disease with maximal diameter 49 mm
• (C) Patients undergoing CABG, valve surgery, or surgery of the ascending aorta
• (D) Asymptomatic with resting LVEF ?50%

Check AnswerSolution[B]:- This man’s echocardiogram shows a dilated aortic root. In this case the likely cause is his long-standing hypertension. In aortic root disease indication for surgery is based on the maximal aortic diameter, regardless of the severity of aortic regurgitation. Patients with Marfan’s syndrome should be offered surgery when their aortic root diameter is ?45 mm; the figure is ?50 mm for patients with a bicuspid aortic valve and ?55 mm for any other patient (including those with aortic root dilatation secondary to hypertension, as in this case). Other indications for surgery in severe aortic regurgitation are: � Symptomatic patients (NYHA class II, III, or IV dyspnoea or angina) � Asymptomatic patients with resting LVEF ?50% � Patients undergoing CABG, valve surgery, or surgery of the ascending aorta. � Asymptomatic patients with resting LVEF >50% with severe LV dilatation-LV end-diastolic dimension >70 mm or LV end-systolic dimension >50 mm (or >25 mm/m2 BSA)

• (A) The jet of regurgitation is anteriorly directed
• (B) The regurgitation is likely to be chronic
• (C) Using PISA to assess the severity of the regurgitant jet is more accurate than measuring the vena contracta
• (D) The MV inflow E-wave velocity is 1.6 m/s; this suggests severe MR

Check AnswerSolution[C]:- The video shows prolapse of the posterior mitral valve leaflet. There is eccentric MR.The vena contracta (VC) can be measured in both central and eccentric jets to estimate the severity of MR. The VC should ideally be measured in the apical four-chamber view. PISA is more accurate for central regurgitant jets. Systolic pulmonary vein flow reversal is specific for severe MR, but is not sensitive

• (A) Start dabigatran
• (B) Start eplerenone
• (C) Urgent repeat coronary angiography
• (D) Stress echocardiography

Check AnswerSolution[D]:- This patient has secondary MR. His recent infarct has led to alteration of his LV geometry (inferior akinesis) resulting in tethering of structurally normal MV leaflets. Ischaemic MR is a dynamic condition and its severity may vary depending upon changes in loading conditions. The ESC Guidelines published in 2012 propose that, because of their prognostic value, lower thresholds of severity using quantitative methods should be used in secondary MR. An ERO ?20 mm2 or a regurgitant volume ?30 mL/beat suggests severe MR. As ischaemic MR is a dynamic condition, stress testing may play a role in its evaluation. An exercise-induced increase in the ERO of ?13 mm2 has been shown to be associated with a large increase in the relative risk of death and hospitalization for cardiac decompensation (ESC Guidelines 2012).

• (A) 0.76 cm2
• (B) 0.80 cm2
• (C) 0.92 cm2
• (D) 1.02 cm2

Check AnswerSolution[B]:- CSAAV = CSALVOT � VTILVOT /VTIAV CSALVOT = 0.785(2.482) CSAAV = 4.82 � 11.61/70.22 CSAAV = 0.798 cm2 = 0.8 cm2

• (A) The patient should be referred for AVR and LIMA to LAD
• (B) His operative mortality is about 3%
• (C) Surgical ablation for AF may be considered
• (D) The patient should have PCI to LAD followed by TAVI

Check AnswerSolution[C]:- This patient has severe symptomatic aortic stenosis and two moderate to severe coronary stenoses with good distal targets. As he has no other significant comorbidity, he should be referred for AVR and two-vessel CABG. PCI and TA VI should be considered only if the patient is judged to be unsuitable for AVR after surgical consultation. In patients with a primary indication for aortic/mitral valve surgery, CABG is recommended for coronary artery stenosis ?70% and should be considered for coronary artery stenosis ?50�70% (ESC Guidelines 2012).This patient’s operative mortality for AVR and CABG is likely to be at least 4.5%. the estimated operative mortality after surgery for valvular heart disease. AF is an independent risk factor for poor outcome after cardiac surgery. The ESC Guidelines for the management of AF recommend that surgical ablation should be considered in patients with symptomatic AF and may be performed in patients with asymptomatic AF undergoing cardiac surgery if feasible with minimal risk.

• (A) Repeat transthoracic echocardiogram in 6 months
• (B) Transoesophageal echocardiography
• (C) Dobutamine stress echocardiography
• (D) Exercise tolerance test for risk stratification

Check AnswerSolution[C]:- This patient has a small aortic valve area and a modest peak gradient in the context of LV impairment (low flow, low gradient AS). In this subset of individuals low-dose dobutamine stress echocardiography can help to distinguish truly severe AS from pseudo-severe AS.

• (A) A statin should be prescribed to reduce the rate of AS progression
• (B) An antihypertensive drug should be prescribed
• (C) The increase in peak velocity of ?0.2 m/s/year suggests that surgery should be considered
• (D) An exercise tolerance test (ETT) is unsafe in asymptomatic severe AS

Check AnswerSolution[B]:- There is no good evidence from randomized controlled trials that statins affect the progression of AS. Exercise testing is contraindicated in symptomatic patients with AS but is recommended in physically active patients for unmasking symptoms and in the risk stratification of asymptomatic patients with severe AS. The development of symptoms or a fall in blood pressure is a predictor of symptom development/poor outcome and therefore is an indication for surgery (ESC Guidelines 2012). In addition, the guidelines recommend that if patients are not physically active or exercise testing is negative, surgery should or may be considered in the presence of specific risk factors and low/intermediate individual surgical risk.

• (A) Plaques with mobile thrombi in the ascending aorta or arch
• (B) Porcelain aorta
• (C) Home oxygen therapy
• (D) Severe peripheral vascular disease

Check AnswerSolution[A]:- TA VI is recommended for patients with symptomatic severe AS who, according to the ‘heart team’, are unsuitable for conventional surgery because of severe comorbidity.Various factors need to be taken into account when making this assessment. A logistic Euro-SCORE of ?20% has been suggested as an indication for TA VI therapy, but in patients with a lower Euro-SCORE other conditions such as a porcelain aorta, a history of chest radiation, and patent coronary bypass grafts make AVR less suitable.

• (A) Associated MR may lead to underestimation of the severity of AS
• (B) Severe AS may lead to overestimation of coexisting MR
• (C) Significant aortic regurgitation (AR) lengthens the Doppler pressure half-time (PHT) in mitral stenosis (MS)
• (D) The presence of significant AR may overestimate the gradient across the aortic valve

Check AnswerSolution[C]:- AR shortens the PHT in mitral stenosis. PHT is a measure of the change in pressure between two cardiac chambers. In significant AR, there is likely to be high LV end-diastolic pressures. This leads to a higher pressure difference between the LV and LA-hence shortening of the PHT in MS. This underestimates the severity of MS.Associated MR leads to underestimation of the severity of AS since decreased stroke volume due to MR lowers the flow (and gradient) across the AV. Similarly, severe AS causes high ventricular pressures leading to overestimation of coexistent MR In mixed aortic valve disease, the presence of significant AR will lead to increased stroke volume and hence flow (and gradient) across the aortic valve. Therefore AR can overestimate the severity of AS.Methods that are less dependent on loading conditions, such as planimetry of valve area, should be utilized.

• (A) Persistent symptoms with reasonable right ventricular dysfunction
• (B) No symptoms-TAPSE 12 mm
• (C) No symptoms-tricuspid annulus systolic velocity 13 cm/s
• (D) No symptoms-RV end-systolic area 30 cm2

Check AnswerSolution[C]:- This patient has severe isolated primary tricuspid regurgitation. Indications for surgery are shown in Box 3.2.