Ischemic Heart Disease Imaging — MCQs
A patient posted for Lap Cholecystectomy had drug eluting stent placed two years back. Patient has no symptoms since then. Which of the following set of investigation should be done in this patient?
What is the investigation of choice for diagnosing a stress fracture?
MUGA scan is not useful in:
Investigation of choice for DVT is -
For pericardial calcifications, which is the best investigation?
Hot spot in heart is seen in which scan
Which radioisotope is PRIMARILY used for detecting acute myocardial infarction rather than assessing myocardial perfusion?
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?
Ketamine is contraindicated in which of the following situations?
True about Cardiovascular disease (CVD)
Ischemic Heart Disease Imaging Indian Medical PG Practice Questions and MCQs
Question 1: A patient posted for Lap Cholecystectomy had drug eluting stent placed two years back. Patient has no symptoms since then. Which of the following set of investigation should be done in this patient?
- A. Coronary angiography, Thallium scan
- B. ECG, CBC, Coronary angiography
- C. ECG, CBC, Stress echocardiography (Correct Answer)
- D. ECG, CBC, Stress echocardiography, coronary angiography
Explanation: **ECG, CBC, Stress echocardiography** - A patient with a **drug-eluting stent (DES)** placed two years prior, who is now asymptomatic, typically requires a **non-invasive cardiac assessment** before surgery. [1] - **Stress echocardiography** is an appropriate investigation to assess for inducible ischemia in an asymptomatic patient with a history of DES, especially when determining readiness for non-cardiac surgery. [1] *Coronary angiography, Thallium scan* - **Coronary angiography** is an invasive procedure and is generally not indicated for asymptomatic patients two years post-DES unless there are new symptoms or high-risk findings on non-invasive tests. [2] - A **Thallium scan** (myocardial perfusion scintigraphy) is a valid stress test, but **stress echocardiography** provides similar information regarding ischemia and ventricular function without radiation exposure. [1] *ECG, CBC, Coronary angiography* - While **ECG** and **CBC** are standard preoperative tests, **coronary angiography** is an invasive procedure and is not the first-line investigation for an asymptomatic patient two years post-DES without other indications. [2] - The patient's asymptomatic status suggests that invasive testing is not immediately warranted for surgical clearance. *ECG, CBC, Stress echocardiography, coronary angiography* - Performing both **stress echocardiography** and **coronary angiography** in an asymptomatic patient two years after DES placement is **redundant** and subjects the patient to an unnecessary invasive procedure. [1], [2] - The results of a non-invasive stress test like stress echocardiography would guide the need for any further invasive intervention.
Question 2: What is the investigation of choice for diagnosing a stress fracture?
- A. X-ray
- B. CT scan
- C. MRI (Correct Answer)
- D. Bone scan
Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** is the most sensitive and specific imaging modality for diagnosing **stress fractures**, especially in their early stages. - It can detect **bone marrow edema** and **periosteal reactions** indicative of stress injury before cortical changes are visible on plain radiographs. *X-ray* - **X-rays** are often the initial investigation, but they have low sensitivity for **stress fractures** in the early stages as bone changes may not be apparent for several weeks. - A positive X-ray for stress fracture typically shows a **sclerotic line** or **periosteal reaction**, but this indicates a more advanced injury. *CT scan* - **CT scans** provide excellent detail of **cortical bone** and can detect subtle fractures not seen on X-rays. - While more sensitive than X-rays, CT has **higher radiation exposure** and is generally less sensitive than MRI for early detection of **bone marrow edema** associated with stress injuries. *Bone scan* - **Bone scans** (scintigraphy) are highly sensitive for detecting increased **osteoblastic activity** associated with stress fractures. - However, they are **less specific** as various conditions can cause increased uptake, and they do not provide detailed anatomical information, making MRI superior for definitive diagnosis and staging.
Question 3: MUGA scan is not useful in:
- A. Stroke volume
- B. Regional wall perfusion (Correct Answer)
- C. Left ventricular ejection fraction
- D. Regional wall motion
Explanation: ***Regional wall perfusion*** - A MUGA scan assesses **ventricular function** through blood pool imaging, evaluating wall motion and ejection fraction. - It does not directly visualize or quantify myocardial perfusion, which is the flow of blood through the coronary arteries to the heart muscle. *Stroke volume* - A MUGA scan accurately measures **end-diastolic volume** and **end-systolic volume**, from which stroke volume (EDV – ESV) can be calculated. - This parameter directly reflects the amount of blood pumped out by the ventricle with each beat. *Left ventricular ejection fraction* - The MUGA scan is considered a gold standard for calculating **left ventricular ejection fraction** (LVEF), a key indicator of cardiac pump function. - It uses a count-based method from gated blood pool images to determine the percentage of blood ejected from the left ventricle. *Regional wall motion* - MUGA scans are highly effective in assessing **regional wall motion abnormalities**, identifying areas of **hypokinesis**, **akinesis**, or **dyskinesis**. - This is crucial for diagnosing and monitoring conditions like myocardial ischemia or infarction, and is a primary utility of the scan.
Question 4: Investigation of choice for DVT is -
- A. Doppler USG (Correct Answer)
- B. MRI
- C. CT scan
- D. Angiography
Explanation: ***Doppler USG*** - **Doppler ultrasonography** is the **first-line investigation** for diagnosing deep vein thrombosis (DVT) due to its high sensitivity, specificity, and non-invasive nature. [1] - It visualizes venous flow, detects thrombus formation, and identifies **non-compressibility of veins**, which is a key diagnostic sign. *MRI* - While **magnetic resonance venography (MRV)** can detect DVT, it is generally reserved for cases where ultrasound is inconclusive or for imaging complex anatomical areas like the pelvic veins. - It is more expensive and less readily available as a primary diagnostic tool compared to Doppler USG. *CT scan* - **Computed tomography venography (CTV)** can visualize DVT, particularly in the pelvis and abdomen, but it involves **ionizing radiation** and requires intravenous contrast. [1] - It is not typically the first choice for DVT diagnosis in the extremities due to radiation exposure and the effectiveness of ultrasound. *Angiography* - **Conventional venography** (angiography) was once considered the gold standard for DVT diagnosis but is now rarely used due to its invasive nature, potential complications (e.g., contrast nephropathy, allergic reactions), and radiation exposure. [1] - It has largely been replaced by non-invasive imaging techniques like Doppler USG.
Question 5: For pericardial calcifications, which is the best investigation?
- A. Ultrasound
- B. CT scan (Correct Answer)
- C. MRI
- D. Transesophageal echocardiography
Explanation: ***Correct: CT scan*** - **CT scans** are highly sensitive and specific for detecting **pericardial calcifications** due to their excellent spatial resolution and ability to measure calcium density (Hounsfield units). - They provide detailed anatomical information about the **pericardium** and can accurately map the extent, location, and thickness of calcified areas. - **CT is the gold standard** for detecting and quantifying pericardial calcification, particularly in constrictive pericarditis. *Incorrect: Ultrasound* - While ultrasound (echocardiography) can visualize the pericardium and may detect calcifications, its ability to definitively identify and characterize **calcifications** is limited compared to CT. - **Acoustic shadowing** from calcifications can obscure underlying structures, making a precise assessment challenging. - Useful for detecting pericardial effusion and thickening, but not optimal for calcification assessment. *Incorrect: MRI* - **MRI excels** in visualizing soft tissues, pericardial inflammation, and fluid collections, but it is **poor at detecting calcium**. - Calcifications typically appear as signal voids (black) on MRI, making it difficult to differentiate them from other structures, air, or motion artifacts. - MRI is valuable for assessing pericardial inflammation and constriction but not the preferred method for calcification. *Incorrect: Transesophageal echocardiography* - TEE offers high-resolution images of cardiac structures and is primarily used for assessing valve function, intracardiac masses, endocarditis, and aortic pathology. - Its utility in detecting and characterizing **pericardial calcifications** is limited compared to CT, especially for diffuse or subtle calcifications. - The pericardium is not optimally visualized with TEE compared to transthoracic echocardiography.
Question 6: Hot spot in heart is seen in which scan
- A. Thallium
- B. Gallium
- C. Albumin labelled
- D. Tc pyrophosphate scan (Correct Answer)
Explanation: ***Tc pyrophosphate scan*** - A **technetium-99m pyrophosphate (Tc-PYP) scan** demonstrates a "hot spot" in the heart in cases of **acute myocardial infarction** due to the tracer binding to calcium deposits in necrotic cardiomyocytes. - This hot spot indicates recent myocardial damage and is particularly useful in diagnosing **amyloidosis** (specifically transthyretin cardiac amyloidosis) where the tracer binds to amyloid fibrils. *Thallium* - **Thallium-201** is used in myocardial perfusion imaging to assess areas of reduced blood flow or infarction, creating a "cold spot" (decreased uptake). - It acts as a potassium analog and is taken up by viable myocardial cells, thus areas of ischemia or necrosis appear as defects rather than hot spots. *Gallium* - **Gallium-67** scans are primarily used to detect infection and inflammation, as well as certain tumors. - While it can accumulate in areas of inflammation in the heart (e.g., myocarditis), it does not create a characteristic "hot spot" associated with acute myocardial infarction. *Albumin labelled* - **Technetium-99m labeled albumin** (e.g., Technetium-99m macroaggregated albumin, MAA) is typically used for lung perfusion scans to diagnose pulmonary embolism or for gastrointestinal bleeding studies. - It is not used for direct assessment of myocardial damage or to create a "hot spot" in the heart for ischemic events.
Question 7: Which radioisotope is PRIMARILY used for detecting acute myocardial infarction rather than assessing myocardial perfusion?
- A. Thallium 201
- B. Tc-99m Sestamibi
- C. Tc-99m Pyrophosphate (Correct Answer)
- D. 18-FDG PET
Explanation: ***Tc-99m Pyrophosphate*** - This radioisotope binds to **calcium deposits** in infarcted myocardial tissue, which accumulate 12-24 hours after injury. - It is particularly useful for detecting **acute myocardial infarction** (hot spot imaging) when cardiac biomarkers may be unreliable or in cases of delayed presentation. - Shows positive uptake in necrotic tissue, making it a "positive" or "hot spot" agent for acute MI. *Thallium 201* - **Thallium 201** is a potassium analog that is actively transported into viable myocardial cells. - It is primarily used for assessing **myocardial perfusion** and viability, showing areas of reduced blood flow or scar tissue. - Acts as a "cold spot" agent - infarcted areas show reduced uptake. *Tc-99m Sestamibi* - **Tc-99m Sestamibi** is a commonly used tracer for **myocardial perfusion imaging (SPECT)**, indicating blood flow to the heart muscle. - It accumulates in viable myocardial cells in proportion to blood flow and is not specific for acute myocardial necrosis. - Used primarily for stress testing and perfusion assessment, not acute infarct detection. *18-FDG PET* - **18-FDG PET** (Fluorodeoxyglucose Positron Emission Tomography) primarily measures **glucose metabolism** in the myocardium. - It is predominantly used to assess **myocardial viability** in areas of hibernating myocardium rather than acute infarction. - Helps distinguish viable but ischemic tissue from scar tissue.
Question 8: 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.
Question 9: Ketamine is contraindicated in which of the following situations?
- A. For analgesia & sedation
- B. Obstetric hemorrhage
- C. Status asthmaticus
- D. Ischemic heart disease (Correct Answer)
Explanation: ***Ischemic heart disease*** - **Ketamine** causes a dose-dependent increase in **heart rate**, **blood pressure**, and **myocardial oxygen demand** due to sympathetic stimulation. - In patients with **ischemic heart disease**, this increased demand can precipitate **myocardial ischemia** or infarction, making it a contraindication. *Status asthmaticus* - **Ketamine** is often beneficial in **status asthmaticus** due to its **bronchodilatory effects**, resulting from direct smooth muscle relaxation and sympathetic stimulation. - It can be a useful alternative when conventional bronchodilators fail to relieve severe bronchospasm. *For analgesia & sedation* - **Ketamine** is widely used for both **analgesia** and **sedation**, particularly in emergency medicine and procedural sedation. - It provides **dissociative anesthesia**, profound pain relief, and maintenance of airway reflexes, making it a valuable agent. *Obstetric hemorrhage* - **Ketamine** can be safely used in **obstetric hemorrhage** as it maintains **uterine tone** and does not relax the uterus, unlike many other anesthetic agents. - This property makes it a preferred choice for anesthesia in parturients with significant bleeding or during Cesarean sections where uterine contraction is crucial.
Question 10: True about Cardiovascular disease (CVD)
- A. Coronary heart disease causes 25% of total deaths
- B. Urban and rural areas have equal incidence
- C. Primordial prevention is best strategy (Correct Answer)
- D. RHD is the most common cause of CVD
Explanation: ***Primordial prevention is best strategy*** - **Primordial prevention** aims to prevent the development of risk factors for CVD in the first place, often starting in childhood. - This strategy targets entire populations with public health initiatives to promote healthy lifestyles and environments, making it the most effective long-term approach to reduce CVD burden. *Coronary heart disease causes 25% of total deaths* - **Coronary heart disease (CHD)** accounts for approximately 16-17% of all deaths globally, not 25%. - While CHD is a leading cause of death, stating it causes 25% of total deaths is an overestimation. *RHD is the most common cause of CVD* - **Rheumatic Heart Disease (RHD)** is an important cause of cardiovascular disease in developing countries including India. - However, **ischemic heart disease** (coronary artery disease) and **hypertension** are the most common causes of CVD globally and in India, not RHD. *Urban and rural areas have equal incidence* - The incidence of cardiovascular disease differs significantly between **urban and rural areas**. - Urban areas typically have higher CVD incidence due to lifestyle factors (sedentary behavior, unhealthy diet, stress), though rural rates are increasing due to epidemiological transition.
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