Cardiovascular Evaluation — MCQs

10 questions

A 40-year-old male patient presents to the Emergency department with central chest pain for 2 hours. The ECG shows ST segment depression and cardiac troponins are elevated. The patient has a positive history of previous PCI 3 months back. He is administered Aspirin, Clopidogrel, Nitrates, and LMWH in the Emergency Department and shifted to the coronary care unit. What is the best recommended course of further action?

Which pre-operative investigation is recommended before surgical procedures in a patient on warfarin therapy?

Most sensitive method of monitoring cardiovascular ischemia in the perioperative period is -

Which of the following drugs need not be stopped before surgery?

In a Down's syndrome patient posted for surgery, the necessary preoperative investigation to be done is –

A patient presents with intense chest pain of 2 hours duration. ECG shows ST depression in leads I and V1 to V4. There is associated T inversion and CPK-MB is elevated. Which of the following should be included in his management?

A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?

Steps in review of patient's history during secondary survey of trauma care can be summarised as

Q10

A patient scheduled for elective inguinal hernia surgery has a history of myocardial infarction (MI) and underwent coronary artery bypass grafting (CABG). What should be included in the preoperative assessment?

Cardiovascular Evaluation Indian Medical PG Practice Questions and MCQs

Question 1: A 40-year-old male patient presents to the Emergency department with central chest pain for 2 hours. The ECG shows ST segment depression and cardiac troponins are elevated. The patient has a positive history of previous PCI 3 months back. He is administered Aspirin, Clopidogrel, Nitrates, and LMWH in the Emergency Department and shifted to the coronary care unit. What is the best recommended course of further action?

A. Early Revascularization with PCI (Correct Answer)
B. Continue conservative management and monitoring of cardiac enzymes and ECG
C. Continue conservative management and plan for outpatient follow-up
D. Immediate Revascularization with Coronary Angiography

Explanation: ***Early Revascularization with PCI*** - The patient presents with **NSTEMI** (ST depression, elevated troponins) and is already on antiplatelet and anticoagulant therapy. **Early revascularization** (ideally within 24 hours for high-risk NSTEMI) is indicated to restore blood flow and prevent further myocardial damage [1]. - Given the patient's history of prior **PCI** and the current NSTEMI presentation, this suggests possible **in-stent restenosis** or progression of coronary artery disease, making revascularization crucial. *Continue conservative management and monitoring of cardiac enzymes and ECG* - While initial conservative management with medications is appropriate, simply continuing monitoring without definitive intervention is insufficient for a **high-risk NSTEMI** patient. - The elevated troponins and ST depression indicate ongoing myocardial injury that requires active management beyond just observation [1]. *Continue conservative management and plan for outpatient follow-up* - This approach is entirely inappropriate for a patient presenting with an **acute coronary syndrome (NSTEMI)**. - Outpatient follow-up is for stable conditions, not for an ongoing cardiac event that requires urgent hospital-based intervention. *Immediate Revascularization with Coronary Angiography* - **Immediate revascularization** (within 90 minutes) is primarily indicated for **STEMI** (ST elevation myocardial infarction). - While coronary angiography will precede PCI, the term "immediate" in this context usually refers to the urgency seen in STEMI; NSTEMI typically warrants "early" rather than "immediate" intervention (within 12-24 hours for high-risk patients like this one) [1].

Question 2: Which pre-operative investigation is recommended before surgical procedures in a patient on warfarin therapy?

A. International Normalized Ratio (INR) (Correct Answer)
B. Partial Thromboplastin Time (PTT)
C. Clotting Time
D. Differential Count

Explanation: ***International Normalized Ratio (INR)*** - The **INR** is specifically used to monitor the effectiveness of **warfarin** therapy, as it standardizes the prothrombin time (PT) for variations in thromboplastin reagents. - Before surgery, an INR measurement helps assess the patient's **coagulation status** and guides decisions on temporary cessation or bridging therapy to minimize bleeding risk. *Partial Thromboplastin Time (PTT)* - **PTT** primarily measures the **intrinsic and common pathways** of coagulation and is used to monitor **heparin** therapy, not warfarin. - While prolonged in some bleeding disorders, it is not the standard test for assessing warfarin's anticoagulant effect. *Clotting Time* - **Clotting time** is a very general and less precise measure of overall coagulation that is **rarely used** in modern clinical practice due to its low sensitivity and specificity. - It does not offer sufficient detail or standardization to guide pre-operative management for patients on warfarin. *Differential Count* - A **differential count** measures the different types of **white blood cells** within a blood sample and is used to diagnose infections, inflammatory conditions, or hematologic disorders. - It provides no information about a patient's coagulation status or the effects of anticoagulant medications like warfarin.

Question 3: Most sensitive method of monitoring cardiovascular ischemia in the perioperative period is -

A. NIBP
B. ECG
C. Pulse oximeter
D. TEE (Correct Answer)

Explanation: ***TEE*** - **Transesophageal echocardiography (TEE)** is the most sensitive method for detecting perioperative myocardial ischemia because it can visualize **regional wall motion abnormalities** and changes in **ventricular function** much earlier than ECG. - **Ischemia** directly impairs the contractility of the affected myocardium, leading to subtle changes in wall motion that TEE can identify. *NIBP* - **Non-invasive blood pressure (NIBP)** monitoring can detect **hemodynamic changes** (like hypotension or hypertension) that may precede or accompany ischemia. - However, these changes are **non-specific** and occur relatively late, making NIBP a less sensitive indicator of early ischemia. *ECG* - **Electrocardiography (ECG)** monitors the electrical activity of the heart and can detect **ST-segment changes** indicative of ischemia. - While useful, ECG changes may appear later than wall motion abnormalities, and **silent ischemia** can be missed if the leads are not optimally placed or if the ischemia does not produce significant electrical changes. *Pulse oximeter* - A **pulse oximeter** measures **oxygen saturation** in the peripheral blood. - It is primarily used to assess **respiratory function** and tissue oxygenation, and it does not directly monitor myocardial ischemia or cardiac function.

Question 4: Which of the following drugs need not be stopped before surgery?

A. High Dose Aspirin
B. Metformin
C. Digitalis (Correct Answer)
D. Warfarin

Explanation: ***Digitalis*** - **Digitalis (digoxin)** is often continued through surgery, especially in patients with **heart failure** or **atrial fibrillation** to maintain cardiac function. - Its cessation could precipitate **cardiac decompensation** or arrhythmias, which are high-risk events during surgery. *High Dose Aspirin* - **High-dose aspirin** should generally be stopped before surgery due to its **antiplatelet effects**, increasing the risk of perioperative bleeding. - The duration of discontinuation depends on the type of surgery and individual patient risk. *Metformin* - **Metformin** should be stopped before surgery due to the risk of **lactic acidosis**, especially in situations involving **renal impairment** or hypoperfusion associated with surgery. - It's typically held on the day of surgery and for 24-48 hours post-operatively, depending on renal function. *Warfarin* - **Warfarin** is a strong oral anticoagulant that must be discontinued before most surgeries to prevent **excessive bleeding**. - It is typically stopped 5 days pre-op, and patients often receive **bridging therapy** with heparin, depending on their risk for thromboembolism.

Question 5: In a Down's syndrome patient posted for surgery, the necessary preoperative investigation to be done is –

A. CT Brain
B. X-ray cervical spine (Correct Answer)
C. Ultrasound Abdomen
D. Echocardiography

Explanation: X-ray cervical spine - Patients with Down syndrome have an increased risk of **atlantoaxial instability (AAI)** due to ligamentous laxity and bony abnormalities, which can lead to spinal cord compression during neck manipulation for intubation. - A **preoperative X-ray of the cervical spine** (flexion/extension views) is crucial to assess for AAI and guide anesthetic management to prevent neurological damage. *CT Brain* - While some Down syndrome patients may have structural brain differences, a **CT brain** is not a routine preoperative investigation for all surgeries unless specific neurological symptoms are present. - It is not primarily indicated for assessing the immediate surgical risks associated with conditions common in Down syndrome, such as atlantoaxial instability. *Echocardiography* - Many Down syndrome patients have congenital heart defects (e.g., **AV canal defects**), and an echocardiogram is essential to evaluate cardiac function and structure, especially for major surgeries. - However, compared to the immediate risk of spinal cord injury during airway management, assessing **atlantoaxial instability** with a cervical spine X-ray takes precedence as a necessary and specific preoperative investigation for general surgery. *Ultrasound Abdomen* - Down syndrome patients have a higher incidence of certain gastrointestinal anomalies (e.g., **duodenal atresia**, Hirshsprung's disease) and often develop premature aging of organs. - An **abdominal ultrasound** is not a standard preoperative screening test unless there are specific abdominal symptoms or indications for evaluating potential anomalies or complications.

Question 6: A patient presents with intense chest pain of 2 hours duration. ECG shows ST depression in leads I and V1 to V4. There is associated T inversion and CPK-MB is elevated. Which of the following should be included in his management?

A. IV metoprolol
B. Aspirin
C. Nitroglycerine drip
D. All of the options (Correct Answer)

Explanation: ***All of the options*** - This patient presents with symptoms and ECG findings consistent with an **ST-elevation myocardial infarction (STEMI)** or **non-ST-elevation myocardial infarction (NSTEMI)**, given the ST depression and T-wave inversions with elevated CPK-MB [4]. - All listed medications (aspirin, IV metoprolol, and nitroglycerine drip) are standard and essential components of early management used to stabilize the patient, reduce myocardial oxygen demand, and prevent further cardiac events [1]. *Aspirin* - **Aspirin** is an antiplatelet agent used to inhibit platelet aggregation and prevent further thrombus formation in acute coronary syndromes [2]. - It is critical for immediate administration in suspected myocardial infarction to reduce mortality and recurrent ischemic events. *IV metoprolol* - **IV metoprolol** (a beta-blocker) reduces myocardial oxygen demand by decreasing heart rate, contractility, and blood pressure [3]. - It is indicated in acute coronary syndromes unless contraindicated, as it can limit infarct size and reduce the risk of arrhythmias. *Nitroglycerine drip* - The **nitroglycerine drip** is a vasodilator that reduces preload and dilates coronary arteries, improving myocardial blood flow and relieving ischemic chest pain [2]. - It is particularly useful for persistent chest pain and helps reduce myocardial oxygen demand.

Question 7: A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?

A. Grade I (Mild claudication)
B. Grade II (Moderate claudication) (Correct Answer)
C. Grade III (Severe claudication)
D. Grade IV (Ischemic rest pain)

Explanation: ***Grade II (Moderate claudication)*** - **Grade II claudication** is characterized by **intermittent claudication** where the patient experiences pain while walking but can **continue walking with effort**. - This level of claudication reflects a moderate degree of peripheral arterial disease, where blood flow is sufficiently compromised to cause pain with exertion but not severe enough to force immediate cessation of activity. - The patient in this scenario can continue ambulation despite discomfort, which is the defining feature of this grade. *Grade I (Mild claudication)* - **Grade I claudication** involves discomfort or pain that the patient can **tolerate without significantly altering their gait or pace**. - In this stage, the pain is minimal, and the patient may perceive it as a dull ache or mild fatigue rather than true pain. - Walking can continue without significant effort or limitation. *Grade III (Severe claudication)* - **Grade III claudication** is marked by pain that is **severe enough to stop the patient from walking within a short distance** (typically less than 200 meters). - The pain forces the patient to rest and recover before they can resume walking. - This represents significant functional limitation in daily activities. *Grade IV (Ischemic rest pain)* - **Grade IV**, also known as **critical limb ischemia**, involves **pain even at rest**, especially in the feet or toes, often worsening at night when the limb is elevated. - This stage indicates severe arterial obstruction and is frequently associated with **ulcers, non-healing wounds, or gangrene**. - This represents advanced peripheral arterial disease requiring urgent intervention. **Note:** This grading system is a simplified clinical classification. The standard medical classifications for peripheral arterial disease are the **Fontaine classification** (Stages I-IV) and **Rutherford classification** (Categories 0-6).

Question 8: Match the following drugs in Column A with their contraindications in Column B. | Column A | Column B | | :-- | :-- | | 1. Morphine | 1. QT prolongation | | 2. Amiodarone | 2. Thromboembolism | | 3. Vigabatrin | 3. Pregnancy | | 4. Estrogen preparations | 4. Head injury |

A. A-1, B-3, C-2, D-4
B. A-4, B-1, C-3, D-2 (Correct Answer)
C. A-3, B-2, C-4, D-1
D. A-2, B-4, C-1, D-3

Explanation: ***A-4, B-1, C-3, D-2*** - **Morphine** is contraindicated in **head injury** as it can increase intracranial pressure and mask neurological symptoms. - **Amiodarone** is contraindicated in patients with **QT prolongation** due to its risk of inducing more severe arrhythmias like Torsades de Pointes. - **Vigabatrin** is contraindicated during **pregnancy** due to its potential for teratogenicity and adverse effects on fetal development. - **Estrogen preparations** are contraindicated in patients with a history of **thromboembolism** due to their increased risk of blood clot formation. *A-1, B-3, C-2, D-4* - This option incorrectly matches **Morphine** with QT prolongation and **Estrogen preparations** with head injury, which are not their primary contraindications. - It also incorrectly links **Vigabatrin** with thromboembolism and **Amiodarone** with pregnancy. *A-3, B-2, C-4, D-1* - This choice incorrectly associates **Morphine** with pregnancy and **Vigabatrin** with head injury, which are not the most critical or direct contraindications. - It also misaligns **Amiodarone** with thromboembolism and **Estrogen preparations** with QT prolongation. *A-2, B-4, C-1, D-3* - This option incorrectly matches **Morphine** with thromboembolism and **Amiodarone** with head injury, which are not their most significant contraindications. - It also incorrectly links **Vigabatrin** with QT prolongation and **Estrogen preparations** with pregnancy.

Question 9: Steps in review of patient's history during secondary survey of trauma care can be summarised as

A. TRIAGE
B. ABCDE
C. AMPLE (Correct Answer)
D. None of the options

Explanation: ***AMPLE*** - The **AMPLE history** is a mnemonic used during the **secondary survey** in trauma care to gather crucial patient information - It stands for **Allergies, Medications, Past medical history/Pregnancy, Last meal, and Events** surrounding the injury. *TRIAGE* - **Triage** is the process of prioritizing patients based on the severity of their condition and the likelihood of benefit from immediate treatment. - It is an initial assessment done to determine the urgency of care, not a detailed historical review for a single patient. *ABCDE* - The **ABCDE approach** (**Airway, Breathing, Circulation, Disability, Exposure**) is part of the **primary survey** in trauma care. - It focuses on identifying and managing immediate life-threatening conditions. *None of the options* - This option is incorrect because **AMPLE** specifically describes the historical review process during the secondary survey.

Question 10: A patient scheduled for elective inguinal hernia surgery has a history of myocardial infarction (MI) and underwent coronary artery bypass grafting (CABG). What should be included in the preoperative assessment?

A. History + c/e + routine labs + V/Q scan
B. History + c/e + routine labs
C. History + c/e + routine labs + stress test (Correct Answer)
D. History + c/e + routine labs + angiography to assess graft patency

Explanation: ***History + c/e + routine labs + stress test*** - A **stress test** is crucial in patients with a history of MI and CABG to assess **myocardial ischemia** and functional capacity, guiding perioperative management. - This evaluation helps determine the patient's **cardiac risk** for non-cardiac surgery and the need for further cardiac optimization. *History + c/e + routine labs + angiography to assess graft patency* - **Coronary angiography** is an invasive procedure and is generally not indicated as a routine preoperative assessment unless there are new, significant cardiac symptoms or signs of **graft dysfunction**. - Assessing graft patency through angiography carries risks and would only be justified if there were strong clinical indications suggesting acute or severe **cardiac ischemia**. *History + c/e + routine labs* - While critical for any preoperative assessment, **routine history, physical examination, and basic laboratory tests** are insufficient for a patient with a significant cardiac history like MI and CABG. - This approach would **underestimate the cardiac risk** and might miss undetected ischemia, leading to adverse perioperative cardiac events. *History + c/e + routine labs + V/Q scan* - A **ventilation-perfusion (V/Q) scan** is primarily used to diagnose **pulmonary embolism** or assess regional lung function. - It does not provide information about myocardial ischemia or cardiac functional capacity, making it **irrelevant** for assessing cardiac risk in this clinical scenario.

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