Cardiac Pathology

Cardiac Pathology Indian Medical PG Question 1: A 45-year-old man presents with intermittent pain in the chest, radiating to the left arm, aggravated by exertion, and relieved by rest. What is the most appropriate initial investigation?

• A. Chest X-ray
• B. Cardiac enzymes
• C. ECG (Correct Answer)
• D. Echocardiogram

Cardiac Pathology Explanation: ***ECG*** - An **ECG** is the most appropriate initial investigation for suspected **angina pectoris** due to its rapid availability and ability to detect signs of **myocardial ischemia** or infarction [1]. - It can reveal changes such as **ST-segment depression** or elevation, **T-wave inversion**, or pathological Q waves [1]. *Chest X-ray* - A **chest X-ray** is useful for evaluating conditions like **pneumonia**, **pneumothorax**, or **heart failure** (cardiomegaly, pulmonary edema). - It is generally not the first-line diagnostic tool for **ischemic heart disease** as it cannot directly visualize coronary arteries or myocardial ischemia. *Cardiac enzymes* - **Cardiac enzymes** (e.g., troponin, CK-MB) are crucial for diagnosing **acute myocardial infarction** but are typically elevated hours after the onset of chest pain. - While important for confirming an MI, they are not the *initial* investigation for transient, exertion-related chest pain suggestive of **stable angina** [1]. *Echocardiogram* - An **echocardiogram** provides detailed information about **cardiac structure** and function, including **wall motion abnormalities**, valve function, and overall ejection fraction [1]. - While valuable, it is usually performed after an ECG to further evaluate the heart's pumping ability and identify **regional wall motion abnormalities** indicative of ischemia, rather than as the very first step [1].

Cardiac Pathology Indian Medical PG Question 2: Cardiomyopathy may be seen in all of the following conditions except.

• A. Duchenne muscular dystrophy
• B. Friedreich's ataxia
• C. Type II glycogen storage disease
• D. Alkaptonuria (Correct Answer)

Cardiac Pathology Explanation: Detailed explanation of cardiomyopathy associations: ***Alkaptonuria*** - Alkaptonuria primarily affects **metabolization of tyrosine** and does not typically lead to cardiomyopathy. - The main clinical manifestation is **ochronosis**, causing dark urine and cartilage damage, without significant cardiac involvement. *Type II glycogen storage* - This condition, also known as **Pompe disease**, can lead to cardiomyopathy due to excessive glycogen accumulation in cardiac tissue. - Patients may exhibit **hypertrophic cardiomyopathy** as a common feature in infancy or early childhood. *Friedreich's ataxia* - This hereditary degenerative disease often leads to cardiac complications such as **hypertrophic cardiomyopathy** and conduction abnormalities [3]. - A classic presentation includes **ataxia** and **loss of deep tendon reflexes**, alongside possible cardiac involvement [2]. *Duchenne muscular dystrophy* - Duchenne muscular dystrophy is characterized by **progressive muscle weakness** and is frequently associated with **dilated cardiomyopathy** due to myocardial degeneration [1] [4]. - Affected individuals often show signs of cardiac dysfunction alongside muscle atrophy and weakness [1].

Cardiac Pathology Indian Medical PG Question 3: Commonest congenital heart disease is:

• A. Patent ductus arteriosus
• B. Atrial septal defect
• C. Ventricular septal defect (Correct Answer)
• D. Mitral valve prolapse

Cardiac Pathology Explanation: ***Ventricular septal defect*** - A **ventricular septal defect (VSD)** is the most frequently observed type of congenital heart disease, accounting for approximately 25-30% of all congenital heart lesions. - It involves an opening in the **interventricular septum**, allowing blood to shunt between the left and right ventricles. *Persistent ductus arteriosus* - While common, **patent ductus arteriosus (PDA)** is not as prevalent as VSDs overall. - PDA is more frequently seen in **premature infants**, but VSDs are the most common in the general population of live births with congenital heart disease. *Atrial septal defect* - **Atrial septal defect (ASD)** is a common congenital heart defect, but its incidence is lower than that of VSDs. - ASDs involve a hole in the **interatrial septum**, leading to shunting of blood between the atria. *Mitral valve prolapse* - **Mitral valve prolapse (MVP)** is a relatively common valvular anomaly but is generally considered a minor congenital heart abnormality or sometimes an acquired condition, not typically classified as the most common "congenital heart disease" in the same category as septal defects. - It involves the leaflets of the **mitral valve bulging into the left atrium** during systole.

Cardiac Pathology Indian Medical PG Question 4: Most common cardiac anomaly in Turner syndrome: CMC (Vellore) 07; CMC (Ludhiana) 13; UPSC 14

• A. Bicuspid aortic valve (Correct Answer)
• B. Bifurcation of aorta
• C. Coarctation of aorta
• D. Aortic stenosis

Cardiac Pathology Explanation: ***Bicuspid aortic valve*** - A **bicuspid aortic valve** is the most frequently observed cardiac anomaly in individuals with Turner syndrome, occurring in approximately 15-30% of cases. - This condition involves the **aortic valve** having two leaflets instead of the usual three, which can lead to complications such as **aortic stenosis** or **aortic regurgitation** over time. *Bifurcation of aorta* - **Aortic bifurcation** is a normal anatomical structure where the aorta divides into the common iliac arteries at the level of L4. - This is not a cardiac anomaly, but rather a standard vascular branching pattern. *Coarctation of aorta* - **Coarctation of the aorta** is a narrowing of the aorta, typically near the ductus arteriosus, and is also common in Turner syndrome (occurring in about 10-15%). - Although common, it is **less frequent** than a bicuspid aortic valve. *Aortic stenosis* - **Aortic stenosis** (narrowing of the aortic valve) can be a consequence of a bicuspid aortic valve, but it is not the primary or most common congenital anomaly itself. - The most common **structural defect** that predisposes to aortic stenosis in Turner syndrome is the bicuspid aortic valve.

Cardiac Pathology Indian Medical PG Question 5: A 55-year-old diabetic presents with chest pain, shortness of breath, and diaphoresis. ECG shows ST elevation. What is the next best step?

• A. PCI (Correct Answer)
• B. Nitroglycerin
• C. Thrombolysis
• D. Heparin

Cardiac Pathology Explanation: ***PCI*** - Percutaneous coronary intervention (PCI) is the **preferred reperfusion strategy** for ST-elevation myocardial infarction (STEMI) if it can be performed within 90 minutes (door-to-balloon time) at a PCI-capable hospital, or within 120 minutes if requiring transfer [1]. - This patient's symptoms (chest pain, shortness of breath, diaphoresis) and **ST elevation on ECG** indicate an acute STEMI, making PCI the most effective and definitive treatment [1]. *Nitroglycerin* - While nitroglycerin can help alleviate chest pain by causing **vasodilation** and reducing cardiac preload and afterload, it does not address the underlying coronary artery occlusion in STEMI. - It is often used as an adjunct, but not as the primary or definitive treatment for **reperfusion** in STEMI. *Thrombolysis* - Thrombolysis is an alternative reperfusion strategy for STEMI, primarily used when **primary PCI is not available** within the recommended timeframes [1]. - Given that PCI is typically available and preferred for STEMI, thrombolysis is considered a second-line option due to higher risks of bleeding and potential for re-occlusion compared to PCI [1]. *Heparin* - Heparin is an **anticoagulant** used in STEMI management to prevent further clot formation and propagation. - It is an important adjunctive therapy, but it does not directly restore blood flow to the ischemic myocardium by dissolving or mechanically removing the occluding thrombus like PCI or thrombolysis.

Cardiac Pathology Indian Medical PG Question 6: Which scan is used to identify viable myocardium after myocardial infarction?

• A. PET scan (Correct Answer)
• B. Strontium 90 scan
• C. Tc 99 scan
• D. Thallium 201 scan

Cardiac Pathology Explanation: ***PET scan*** - Positron Emission Tomography (PET) is the **gold standard** for assessing myocardial viability, particularly using **FDG-PET**, which identifies metabolically active (viable) tissue. - Areas that show perfusion but no metabolic activity on FDG-PET indicate **hibernating myocardium**, which can recover function after revascularization. *Tc 99 scan* - **Technetium-99m sestamibi** scans assess myocardial perfusion, identifying areas of reduced blood flow (ischemia) or absent flow (infarction). - While useful for perfusion, it is **less sensitive** than PET for distinguishing between necrotic tissue and viable, but dysfunctional, myocardium. *Strontium 90 scan* - **Strontium-90** is primarily a beta emitter used in brachytherapy and **radiation sources**, not typically in diagnostic cardiac imaging for myocardial viability. - It is **not a standard radiotracer** for assessing myocardial perfusion or metabolism. *Thallium 201 scan* - **Thallium-201** is a potassium analog used in myocardial perfusion imaging to detect ischemia and infarction. - While it can show **redistribution** into viable myocardium, its resolution and ability to differentiate viable from non-viable tissue are **inferior to PET imaging**.

Cardiac Pathology Indian Medical PG Question 7: A 55-year-old male presents with severe, crushing chest pain and shortness of breath. ECG shows ST elevation in the inferior leads. What is the most appropriate immediate management?

• A. Beta blockers
• B. Oxygen and nitroglycerin
• C. Percutaneous coronary intervention (Correct Answer)
• D. Thrombolysis

Cardiac Pathology Explanation: Percutaneous coronary intervention - The patient's symptoms (severe, crushing chest pain, shortness of breath, ST elevation in inferior leads) are classic for an ST-elevation myocardial infarction (STEMI) [1]. - Primary percutaneous coronary intervention (PCI) is the preferred treatment for STEMI when available within recommended timeframes, as it directly opens the occluded coronary artery to restore blood flow [2]. Beta blockers - While beta blockers are part of long-term STEMI management, they are not the most appropriate immediate intervention when revascularization is paramount. - They can be administrated after reperfusion therapy, typically within 24 hours (unless contraindicated), to reduce myocardial oxygen demand [2]. Oxygen and nitroglycerin - Oxygen is indicated for hypoxia, but routine use in normoxia has not shown benefit; nitroglycerin can relieve chest pain but does not address the underlying coronary occlusion in STEMI. - These therapies are largely supportive and do not treat the root cause of STEMI, which is an occluded coronary artery [1]. Thrombolysis - Thrombolysis is an alternative reperfusion strategy for STEMI when PCI is not available or cannot be performed within the recommended time [2]. - Given that the question does not suggest PCI is unavailable, it is not the most appropriate immediate choice in comparison to PCI for STEMI [2].

Cardiac Pathology Indian Medical PG Question 8: The treatment of acute myocardial infarction includes which of the following?

• A. Oral anticoagulants
• B. Aspirin (Correct Answer)
• C. Heparin
• D. Alteplase

Cardiac Pathology Explanation: ***Aspirin*** - **Aspirin** is a cornerstone of acute myocardial infarction treatment due to its **antiplatelet effects**, which reduce thrombus formation in the coronary arteries [4]. - It works by **irreversibly inhibiting cyclooxygenase-1 (COX-1)**, thereby preventing the synthesis of thromboxane A2, a potent platelet aggregator [4]. *Heparin* - **Heparin** (unfractionated or low molecular weight) is an **anticoagulant** often used adjunctively in acute MI, particularly in patients undergoing percutaneous coronary intervention (PCI) or with concurrent atrial fibrillation [1]. - Its primary role is to **prevent further clot formation** rather than directly dissolving existing clots, making it not the initial, primary treatment for MI itself. *Alteplase* - **Alteplase** is a **fibrinolytic agent** used in acute ST-elevation myocardial infarction (STEMI) to **dissolve existing clots** and restore blood flow [3]. - While effective, it is not universally indicated for *all* acute MI cases and has specific contraindications, making it a secondary rather than primary initial treatment choice in many scenarios when compared to aspirin [2]. *Oral anticoagulants* - **Oral anticoagulants** (e.g., warfarin, direct oral anticoagulants) are primarily used for **long-term prevention** of thromboembolic events, such as in atrial fibrillation or after venous thromboembolism. - They are generally **not used in the immediate acute phase of MI** as the primary treatment due to their slower onset of action and different mechanisms compared to antiplatelet drugs like aspirin.

Cardiac Pathology Indian Medical PG Question 9: Match List-I with List-II and select the correct answer using the code given below the Lists:

• A. A→3 B→4 C→2 D→1
• B. A→4 B→3 C→2 D→1
• C. A→4 B→3 C→1 D→2
• D. A→3 B→4 C→1 D→2 (Correct Answer)

Cardiac Pathology Explanation: ***A→3 B→4 C→1 D→2*** - This option correctly matches each anticancer drug to its characteristic adverse effect: **Cisplatinum (A)** with **tubular necrosis (3)**, **Adriamycin (B)** with **cardiomyopathy (4)**, **Bleomycin (C)** with **pulmonary fibrosis (1)**, and **Cyclophosphamide (D)** with **haemorrhagic cystitis (2)**. - These drug-toxicity associations are clinically important for monitoring and managing patients on chemotherapy. *A→3 B→4 C→2 D→1* - This option incorrectly matches Bleomycin with haemorrhagic cystitis (should be pulmonary fibrosis) and Cyclophosphamide with pulmonary fibrosis (should be haemorrhagic cystitis). - While Cisplatinum and Adriamycin are correctly paired, the last two associations are reversed. *A→4 B→3 C→2 D→1* - This option incorrectly matches Cisplatinum with cardiomyopathy (should be tubular necrosis) and Adriamycin with tubular necrosis (should be cardiomyopathy). - Additionally, Bleomycin and Cyclophosphamide complications are also incorrectly paired. *A→4 B→3 C→1 D→2* - This option incorrectly swaps the complications for Cisplatinum and Adriamycin: Cisplatinum is matched with cardiomyopathy (should be tubular necrosis) and Adriamycin with tubular necrosis (should be cardiomyopathy). - While Bleomycin and Cyclophosphamide are correctly paired with their respective complications, the first two associations are incorrect.

Cardiac Pathology Indian Medical PG Question 10: Assertion: Myocarditis is seen as a complication in faucial diphtheria. Reason: It is due to the exotoxin produced by Corynebacterium diphtheriae.

• A. Assertion is false, reason is true.
• B. Assertion is true, reason is true but reason is not the correct explanation of the assertion.
• C. Assertion is true, reason is true.
• D. Assertion is true, reason is true and reason is the correct explanation of the assertion. (Correct Answer)

Cardiac Pathology Explanation: ***Assertion is true, reason is true and reason is the correct explanation of the assertion*** **Analysis of Assertion:** - Myocarditis is indeed a **well-documented complication** of faucial (pharyngeal) diphtheria, occurring in 10-25% of cases - It typically appears in the **second to third week** of illness and is a major cause of mortality in diphtheria - Cardiac involvement can range from asymptomatic ECG changes to severe heart failure and cardiogenic shock **Analysis of Reason:** - The **diphtheria exotoxin** produced by *Corynebacterium diphtheriae* is directly responsible for myocardial damage - The toxin inhibits protein synthesis by **ADP-ribosylation of elongation factor-2 (EF-2)**, leading to cell death - Cardiac myocytes are particularly vulnerable to this toxin, resulting in **toxic myocarditis** **Why the reason is the correct explanation:** - The mechanism of myocarditis in diphtheria is specifically through the **cardiotoxic effect of the exotoxin**, not through immune mechanisms or bacterial invasion - This establishes a direct **cause-and-effect relationship** between the exotoxin (reason) and myocarditis (assertion) *Incorrect Options:* *Assertion is false, reason is true* - This is incorrect because the assertion is definitely true - myocarditis is a classic complication of diphtheria documented in all standard microbiology and infectious disease texts *Assertion is true, reason is true but reason is not the correct explanation of the assertion* - This is incorrect because the exotoxin IS the direct cause of myocarditis in diphtheria - the reason perfectly explains the assertion through a clear pathophysiological mechanism *Assertion is true, reason is true* - While this correctly identifies both statements as true, it fails to acknowledge the **causal relationship** - the exotoxin doesn't just happen to be produced; it is the specific mechanism causing the myocarditis

Cardiac Pathology Flashcard 1 of 10

Question: _____, secondary to rheumatic fever, is characterized by small inflammatory vegetations along valvular lines of closure, which cause regurgitation

Answer: Endocarditis

Cardiac Pathology Flashcard 2 of 10

Question: In rheumatic heart disease, subendocardial lesions may induce irregular thickenings called _____

Answer: McCallum plaques

Cardiac Pathology Flashcard 3 of 10

Question: _____ cardiomyopathy may be caused by endocardial fibroelastosis, which is a thick fibroelastic tissue in the endocardium; most commonly affects young children

Answer: Restrictive

Cardiac Pathology Flashcard 4 of 10

Question: The hyaline, eosinophilic deposits seen on the biopsy point to a diagnosis of cardiac amyloidosis, which most commonly leads to _____ cardiomyopathy.

Answer: restrictive

Cardiac Pathology Flashcard 5 of 10

Question: On biopsy of a heart with myocarditis, a _____ infiltrate with focal necrosis is highly indicative of viral myocarditis

Answer: lymphocytic

Cardiac Pathology Flashcard 6 of 10

Question: One complication of atherosclerosis is _____, which may result from plaque rupture with thrombosis of the coronary artery

Answer: myocardial infarction

Cardiac Pathology Flashcard 7 of 10

Question: The hyaline, eosinophilic deposits seen on the biopsy point to a diagnosis of cardiac amyloidosis, which most commonly leads to _____ cardiomyopathy.

Answer: restrictive

Cardiac Pathology Flashcard 8 of 10

Question: Hypertrophic cardiomyopathy is characterized by myofibrillar hypertrophy with _____ and fibrosis on biopsy

Answer: disarray

Cardiac Pathology Flashcard 9 of 10

Question: Aschoff's bodies in rheumatic heart disease shows _____ necrosis.

Answer: fibrinoid

Cardiac Pathology Flashcard 10 of 10

Question: _____ disease is a glycogen storage disease associated with hypertrophic cardiomyopathy

Answer: Pompe