Cardiology Quiz | Practice MCQ #mcq.ImBooz

• (A) Normal orientation of the cardiac apex within the thorax, e.g. leftward pointing cardiac apex
• (B) Normal orientation of the cardiac atria, e.g. morphological left atrium on the left and morphological right atrium on the right
• (C) Mirror image of the cardiac structures and abdominal viscera, e.g. left-sided structures on the right and vice versa
• (D) Normal orientation of the cardiac structures but with mirror images of the abdominal viscera

Check AnswerSolution[B]:- B. Situs solitus refers to a normal orientation of the cardiac structure and abdominal viscera relative to the midline. For congenital heart disease the anatomy is defined from the atria (e.g. the morphological left atrium can be identified by its appendage but may be on the right side, this is situs inversus).

• (A) A dilated and hyperdynamic RV with evidence of acute TR secondary to raised pulmonary pressure
• (B) A jet of colour flow extending back into the RVOT from the pulmonary artery in the short-axis parasternal view
• (C) A jet of colour extending from the right coronary sinus into the right ventricle
• (D) A jet of colour across the apical interventircular septum in the four-chamber view

Check AnswerSolution[C]:- C. This case describes a young patient with sinus of Valsalva aneurysm rupture (acute symptoms, pulmonary congestion, and continuous murmur). Answer B describes a PDA which can be associated with a continuous murmur and endocarditis but not such an acute presentation. PE does not cause pulmonary congestion or a continuous murmur.

• (A) As the patient is asymptomatic there is no indication for venesection
• (B) Daycase venesection should be arranged with volume replacement based on the Hb to prevent hyperviscosity complications
• (C) The haematocrit (Hct) should be checked; if Hct > 65%, daycase isovolumic venesection is indicated
• (D) The iron status should be checked first; in the presence of iron deficiency this should be treated first, prior to venesection

Check AnswerSolution[A]:- A. Polycythaemia is a physiological adaptive process to chronic cyanosis. Venesection should be avoided unless there are clear hyperviscosity symptoms. Venesection is not associated with a reduced risk of stroke and may cause iron deficiency and circulatory collapse without careful volume replacement.

• (A) The patient is at risk of malignant arrhythmias and sudden cardiac death; urgent haemodynamic assessment and consideration of an ICD is appropriate
• (B) I t is likely that the patient is experiencing paroxysmal SVTs or symptomatic ectopics; arrange an outpatient 24-hour tape
• (C) I t is common for patients with ToF repair to develop non-sustained RVOT arrhythmias at the site of the surgical scar, and beta-blockers are the initial treatment of choice for symptoms
• (D) I t is possible that the symptoms represent haemodynamic deterioration; an echocardiogram should be arranged to document progression of PR and RV dilatation

Check AnswerSolution[A]:- A. The duration of the QRS is proportional to the size of the RV. It has been shown that a QRS >180 ms is a highly sensitive marker for VT and SCD in previous ToF repair (SCD accounts for a third of late deaths). This patient’s case should be urgently discussed and the option of an ICD considered. Haemodynamic assessment with echocardiography is also important as the PR or RV dilatation may have progressed, with the need for PV intervention. Non-sustained VT is common but is not an indicator of SCD risk. Antiarrhythmics are not indicated if the patient is asymptomatic. The VT is normally of RVOT origin (infundibulectomy or VSD patch). Development of major arrhythmias (AF/flutter and sustained VT) normally reflects haemodynamic deterioration (PR, RV dilatation) and therefore haemodynamic assessment and correction of the lesion can correct the arrhythmia (with the option of surgical/catheter ablation).

• (A) There is a large PFO which represents a significant risk factor for recurrent stroke; once the patient has recovered, inpatient transcatheter PFO closure is indicated
• (B) There is clear evidence of paroxysmal AF: in the context of stroke and cardiovascular risk factors, we would recommend anticoagulation once beyond the acute risk of haemorrhagic transformation; no further treatment for the PFO is required whilst on anticoagulation
• (C) The patient is young and should have pulmonary vein isolation and a flutter ablation with transcatheter left atrial appendage closure and PFO closure
• (D) TOE is the next step to confirm the presence and anatomy of the shunt

Check AnswerSolution[B]:- B. This case describes a relatively young patient with a number of risk factors for stroke. Despite having risk factors for atherosclerosis, because of his age (and clear carotid Doppler scans) other foci for embolic stroke have been pursued. Two possibilities have been identified: left atrial thrombus as a result of AF or a paradoxical embolus via the PFO. The question asks for the immediate strategy. Anticoagulation protects against both sources of embolus and so is the immediate treatment of choice. PFO closure will not protect against LA thrombus due to PAF and anticoagulation would still be required. Complex ablation and device treatment may be a future option based on progress, but needs careful discussion. TOE is not required after a suggestive positive bubble test, which is the preferred modality to confirm a PFO. Periprocedural TOE is used to guide transcatheter closure. The AF is likely to be due to uncontrolled hypertension (LVH) and strict control with an ACE inhibitor can reduce the AF burden.

• (A) A palliative procedure when a biventricular surgical repair is not possible: the systemic venous blood is directly routed into the pulmonary arteries bypassing the ventricle
• (B) When a biventricular surgical repair is not possible the systemic venous blood is directly routed into the pulmonary arteries bypassing the ventricle; life expectancy is near normal
• (C) I t is a procedure for the treatment of transposition of the great arteries but is no longer performed; the systemic venous blood is routed via baffles to the morphological left ventricle (subpulmonary ventricle) and the pulmonary venous blood is routed to the morphological RV (systemic ventricle)
• (D) I t consists of an SVC-to-PA shunt to increase pulmonary blood flow in congenital cyanotic heart disease when pulmonary flow is low

Check AnswerSolution[A]:- A. � A describes the Fontan operation for complex congenital cyanotic heart disease when a biventricular repair is not possible. There are a number of modifications. The modern technique is the total cavopulmonary connection which routes blood directly to the Pas avoiding the atrium.

• (A) ASD
• (B) VSD
• (C) PFO
• (D) P rimary respiratory disease with right heart changes

Check AnswerSolution[A]:- A. Secundum and primum (AVSD) defects can be clearly seen on transthoracic echo. However, sinus venosus defects may not be seen. This patient has signs and a suspicion of an ASD physiology type left-to-right shunt. This includes anomalous pulmonary venous drainage, which is associated with superior sinus venosus ASD. He should have further imaging in the form of TOE or CT/CMR to identify the pulmonary venous drainage and look for a less obvious ASD. PFOs cause no haemodynamic anatomical change. Haemodynamically significant VSDs result in left ventricular volume loading and increased pulmonary flow with eventual pulmonary hypertension, as do PDAs (not right-sided volume loading).

• (A) Transcatheter ASD device closure
• (B) Surgical ASD closure
• (C) ACE inhibitor treatment to reduce the shunt and protect the right heart
• (D) Monitoring in clinic for signs of severe right heart dilatation

Check AnswerSolution[B]:- B. This patient has a sinus venosus ASD with symptoms and evidence of haemodynamic anatomical change. The defect is in the superior atrium at the entrance of the SVC into the RA (almost as if the SVC overrides the atrial septum). Currently, transcatheter solutions are not available and surgery is the treatment of choice. Sinus venosus ASDs are often associated with anomalous pulmonary venous drainage which requires surgical correction. If the shunt is not corrected, this may result in irreversible right heart dysfunction, pulmonary hypertension (late), or the development of atrial arrhythmias such as AF which complicate the situation. ACE inhibitors reduce LA pressure, and therefore in theory can reduce the shunt, but this is not a suitable treatment.

• (A) A 25-year-old with repaired ToF and severe pulmonary regurgitation with a mildly dilated and mildly impaired right ventricle
• (B) A 32-year-old with idiopathic pulmonary arterial hypertension, which has responded well to bosentan, who has a right atrial to right ventricular pressure drop of 45 mmHg
• (C) A 39-year-old patient with moderate mitral regurgitation and good left ventricular function
• (D) An 18-year-old with a single-ventricle circulation and a total cavopulmonary connection operation for tricuspid atresia, normally saturated and with good LV function

Check AnswerSolution[B]:- B. Pregnancy is well tolerated in most patient groups, even those with a Fontan circulation. It is extremely high risk in patients with severe systemic ventricular impairment, those with a dilated aorta, those with pulmonary hypertension, and those with severe obstructive valve lesions due to the high risk of maternal morbidity. These patients should be counselled against pregnancy. The risk of mortality in patients with pulmonary hypertension is high. It has remained one of the leading causes of death in pregnancy for many decades, along with myocardial infarction, aortic dissection, and peripartum cardiomyopathy. Furthermore, bosentan is contraindicated in pregnancy.

• (A) 1�2%
• (B) 8�10%
• (C) 0.5
• (D) 4�5%

Check AnswerSolution[D]:- D. Most congenital heart disease is multifactorial in origin. There are some familial syndromes and some with autosomal dominant inheritance but generally the risk of inheritance of many lesions is 4�5%. Patients with left-sided obstructive lesions and atrioventricular septal defects have a slightly higher risk of passing on a defect-in the region of 6�8%. The risk of defects being passed on by fathers is lower.

• (A) Sterilization
• (B) Condoms
• (C) Mirena intra-uterine system
• (D) Depo Provera

Check AnswerSolution[C]:- C. Patients with heart disease are often unaware of the most suitable contraception for them and the quality of advice offered is universally poor. Generally speaking, progesterones (including the morning-after pill) are safe for all cardiac conditions. Condoms have a high failure rate and should not be used in women in whom avoiding pregnancy is important. The combined pill should be avoided in those in whom clotting is hazardous, i.e. dilated cardiomyopathy, Fontan, Mustard/Senning, AF/atrial flutter, previous clot,cyanosis/shunt, pulmonary hypertension, and mechanical valves. The progesterone implant and progesterone coil (Mirena IUS) are well tolerated and much more effective than sterilization. Consideration needs to be given to women on warfarin because of the risk of heavy/irregular bleeding with the mini-pill or Depo. Additionally Depo and implanted devices can result in painful bruising at the site of injection. The Mirena coil results in a lighter period, which is useful for women on warfarin and is highly effective.

• (A) Atenolol
• (B) Simvastatin
• (C) Aspirin
• (D) Amlodipine

Check AnswerSolution[B]:- B. Statins are categorized by the FDA as Category X because they inhibit mevalonic acid and have been shown to cause skeletal abnormalities in fetuses as well as resulting in fetal death. Although it has been proposed that statins in pregnancy may have benefits for treatment of pre-eclampsia this remains unproven and is not an accepted clinical indication. Atenolol, clopidogrel, and amlodipine can be used in pregnancy if the benefit to the mother outweighs the risk to the fetus. Aspirin is best avoided in the first trimester but is safe later in pregnancy in doses of <150 mg od.

• (A) Esmolol
• (B) Amiodarone
• (C) Verapamil
• (D) Digoxin

Check AnswerSolution[A]:- A. Tachyarrhythmias in labour are often catecholamine driven and therefore beta-blockers are the most effective and appropriate drugs. The short half-life of esmolol is useful as it terminates the tachyarrhythmia without having a prolonged effect on labour. The others are less likely to be effective. Amiodarone is contraindicated in pregnancy.

• (A) Methyldopa, labetolol, nifedipine
• (B) Nifedipine, captopril, bendroflumethazide
• (C) Metoprolol, methyldopa, bendroflumethazide
• (D) Enalapril, labetolol, doxazosin

Check AnswerSolution[A]:- A. No drugs have been subjected to randomized controlled trials in pregnant women so safety data are based on observational data in humans and animal fetuses. FDA categorization is helpful. Briefly, Category A drugs are proven to be safe in clinical trials; no drugs are in this category.

• (A) Warfarin throughout pregnancy switching to heparin 2�3 weeks before delivery
• (B) L ow molecular weight heparin for weeks 6�12 and warfarin for weeks 12�38, switching to heparin 2 weeks before delivery
• (C) L ow molecular weight heparin throughout with four-weekly monitoring of anti-Xa levels
• (D) L ow molecular weight heparin and aspirin throughout with four-weekly monitoring of anti-Xa levels

Check AnswerSolution[A]:- A. Warfarin crosses the placenta and can cause spontaneous abortion, stillbirth, neonatal death, and prematurity. In addition, warfarin is teratogenic, particularly in weeks 6�9, resulting in warfarin embryopathy (nasal hypoplasia, saddle-shaped nasal bridge, skeletal defects, short fingers and toes, low birth weight, and developmental delay). However, the incidence of embryopathy in fetuses where the mother has been given warfarin in doses <5 mg daily is zero. Therefore the risk for this particular patient, who is on 4 mg of warfarin, is low. Heparin does not cross the placenta and so is safe for the fetus, but there is an increased incidence of valve thrombosis which can result in death. Low molecular weight heparin has not been shown to avoid this problem, although the incidence of valve thrombosis is lower. The position of the valve should also be considered. The mitral valve is more likely to thrombose than the aortic valve, and pregnancy is a hypercoagulable state with increased activation of prothrombin 1 and 2, TAT (thrombin�antithrombin complex), and D-dimer. Therefore the safest option for this patient is to continue warfarin throughout pregnancy. Warfarin should be stopped several weeks before delivery to reduce the risk of neonatal intracranial haemorrhage. Warfarin takes several weeks to be metabolized by the fetal liver.

• (A) Modified Bruce treadmill testing to assess the significance of the likely mild aortic stenosis
• (B) Nothing-all the above are normal findings in pregnancy and the patient should be reassured
• (C) Cardiac magnetic resonance imaging-the patient may have a right ventricular cardiomyopathy
• (D) H olter monitoring to look for arrhythmias

Check AnswerSolution[B]:- B. History and examination can be misleading as dyspnoea, palpitations, and peripheral oedema are common in pregnant women and hypotension and a collapsing pulse are the norm. Over >90% of pregnant women will have an ejection systolic murmur. Sinus tachycardia, right bundle branch block, and premature ventricular and atrial complexes are common in pregnancy, and in the third trimester the ECG often shows left axis deviation, Q III, T III, and inferolateral ST depression, and T-wave inversion. Velocities across the outflow tract in pregnancy are usually increased because of the increased volume load, and chamber sizes on the echocardiogram are increased.

• (A) U rgent thrombolysis to avoid the radiation risk of coronary angiography to the baby
• (B) P rimary angioplasty optimally with a drug eluting stent
• (C) P rimary angioplasty optimally avoiding a drug eluting stent
• (D) Emergency delivery and subsequent standard primary angioplasty

Check AnswerSolution[C]:- C. Myocardial infarction in pregnancy is rare but is increasing because mothers are tending to be older with increased incidences of obesity, diabetes, and smoking. Coronary dissection can occur, but now myocardial infarction due to coronary atheroma is more common. The adverse haemodynamics in pregnancy plus increased oxygen consumption and hypercoagulability increase the risk. Mortality is high (around 11%, although it is now decreasing in the primary PCI era). The aim should be to save the mother’s life and so radiation is not a concern. The life of the baby depends on survival of the mother (fetal mortality is approximately 9%, mostly due to maternal death). Conservative management is not appropriate. Interventional strategies and the subsequent need for antiplatelet agents are complicated and depend on a number of factors. The need for Clopidogrel precludes regional anaesthesia which is desirable post infarct. The Genous stent would currently require the shortest duration of dual antiplatelet treatment for around a week compared to 28 days for a bare metal stent.

• (A) Termination of pregnancy is justified on medical grounds
• (B) An ACE inhibitor and beta-blocker should be started as soon as possible
• (C) P rescribing a nitrate and hydralazine may cause the symptoms to subside
• (D) The patient should rest and be admitted to hospital for this if necessary

Check AnswerSolution[B]:- B. ACE inhibitors are absolutely contraindicated in the second and third trimesters of pregnancy because of the risk of renal defects, oligohydramnios, and limb contractures Hydralazine and nitrate is a safe alternative. Rest (bed rest in hospital) is likely to be required in this case. The aim would be for the fetus to reach viability without compromising the mother. Termination of pregnancy would be justified in this case as there is a high risk of pulmonary oedema, intractable heart failure, stroke, and fetal loss. Patients with occult left ventricular dysfunction and obstructive valve disease usually present around this point in gestation as this is when their increase in cardiac output and plasma volume during pregnancy begins to peak (apart from in labour). The haemodynamic changes in pregnancy are profound.