Cardiology Practice Questions

Q: A 61-year-old man presents with progressive dyspnea and fatigue. Echocardiogram shows severe aortic stenosis with valve area $0.5\mathrm{cm}^2$. He develops syncope during exercise testing. What is the most appropriate management?

Urgent aortic valve replacement. ***Urgent aortic valve replacement*** - The patient has **severe aortic stenosis** (valve area $0.5\mathrm{cm}^2$) and is highly symptomatic, indicated by **syncope during exercise**, which significantly increases the risk of sudden cardiac death. - **Aortic valve replacement (AVR)** or TAVR is the definitive and urgent treatment required for symptomatic severe AS to alleviate symptoms and improve survival. *Medical management* - Medical therapy does not treat the underlying **fixed mechanical obstruction** of the aortic valve, making it ineffective for severe symptomatic AS. - Relying solely on medical management in this scenario leads to a very poor prognosis due to the high risk of **sudden cardiac death**. *Balloon aortic valvuloplasty* - BAV is primarily a temporary measure, often used as a **bridge to AVR/TAVR** or in hemodynamically unstable patients, due to its high rate of restenosis. - Given the patient is likely a surgical candidate, BAV is not considered the **definitive long-term solution** for severe AS. *Heart transplantation* - Heart transplantation is reserved for **end-stage heart failure** that is refractory to other medical and surgical options. - The primary pathology (severe AS) is surgically addressable via AVR, making transplantation an **inappropriate** initial therapy. *ICD insertion* - Syncope in severe AS is typically due to **flow limitation** and **exertional hypotension** caused by the fixed obstruction, rather than primary ventricular tachyarrhythmias. - Treating the underlying mechanical pathology with AVR resolves the cause of the syncope and the high risk of sudden death; therefore, an **ICD is not indicated**.

Q: A 57-year-old diabetic man presents with a non-healing foot ulcer for 3 months. Ankle-brachial pressure index is 0.3. What does this indicate?

Severe arterial disease. ***Severe arterial disease*** - An **Ankle-Brachial Pressure Index (ABPI)** of **0.3** indicates severely reduced blood flow to the lower extremities. - This severe reduction in arterial supply is consistent with the patient's **non-healing foot ulcer** and diabetes, a major risk factor for peripheral arterial disease. *Normal arterial supply* - **Normal ABPI** values typically range from **0.90 to 1.30**, which is significantly higher than the given 0.3. - An ABPI of 0.3 suggests profound compromise, far from normal blood flow required for tissue healing. *Mild arterial disease* - **Mild arterial disease** is generally indicated by an **ABPI between 0.70 and 0.90**. - An ABPI of 0.3 is well below this range, signifying much more severe impairment of arterial flow. *Moderate arterial disease* - **Moderate arterial disease** corresponds to an **ABPI between 0.40 and 0.69**. - The patient's ABPI of 0.3 is lower than this range, indicating a more critical level of arterial obstruction. *Venous disease* - The **ABPI** is a diagnostic tool primarily used to assess **arterial insufficiency**, not venous disease. - While venous disease can cause ulcers, an ABPI of 0.3 specifically points to significant **peripheral arterial disease** as the underlying cause.

Q: A 53-year-old woman presents with progressive dyspnea and fatigue. Echocardiogram shows severe mitral regurgitation with flail posterior leaflet. LV function is normal but LV end-systolic dimension is 45mm. What is the most appropriate management?

Mitral valve repair. ***Mitral valve repair***- Repair is the preferred management for **severe primary mitral regurgitation (MR)**, especially when the mechanism is degenerative (like a **flail leaflet**), as it provides better long-term survival and preserves native annular-ventricular continuity.- Surgery is mandated because the patient is **symptomatic** (dyspnea and fatigue) and meets criteria for severe MR (along with an **LVESD of 45 mm**, which is an independent indication for surgery even in asymptomatic patients with preserved LVEF).*Medical management*- Medical management (e.g., ACE inhibitors/beta-blockers) is appropriate only for **asymptomatic patients** who do not meet surgical LV dimensional or functional thresholds.- It is **insufficient** to halt the progression or reduce mortality in symptomatic severe primary MR, which requires definitive surgical correction.*Mitral valve replacement*- Replacement is reserved for valves deemed **unrepairable** due to extensive destruction, calcification, or complex pathology.- Repair is favored because it avoids the risks associated with prosthetic valves, such as lifelong **anticoagulation** (for mechanical valves) and prosthetic valve dysfunction.*Heart transplantation*- This procedure is reserved for **end-stage heart failure** (NYHA Class III/IV symptoms) that is refractory to all other medical and surgical therapies.- The patient has **normal LV function** (preserved LVEF), making transplantation completely unnecessary and inappropriate.*Balloon valvuloplasty*- This intervention is the primary treatment for severe, pliable **mitral stenosis**, most commonly due to rheumatic disease.- It is **contraindicated** in severe MR, particularly MR secondary to leaflet prolapse or flail, as it would worsen the severity of the regurgitation.

Q: A 46-year-old man presents with progressive dyspnea and fatigue. Echocardiogram shows severe mitral stenosis with valve area 0.7 cm². He is in atrial fibrillation with rapid ventricular response. What is the most appropriate initial management?

Rate control with digoxin. ***Rate control with digoxin***- Rapid ventricular rate in **atrial fibrillation** significantly reduces **diastolic filling time**, which is crucial for adequate **left ventricular filling** in severe **mitral stenosis (MS)**.- Rate control (e.g., with rate-limiting calcium channel blockers, beta-blockers, or **digoxin** in the setting of MS, especially if associated with heart failure) is the immediate priority to alleviate acute symptoms of heart failure.*Immediate cardioversion*- Cardioversion is generally postponed until the patient is properly **anticoagulated** (due to high risk of systemic **thromboembolism**) unless the patient is **hemodynamically unstable** (e.g., shock/hypotension).- In severe MS, AF often recurs due to chronic **left atrial enlargement** and high pressure, making rate control the preferred strategy over rhythm control initially.*Balloon mitral valvuloplasty*- This is the preferred definitive treatment for symptomatic severe MS but is an invasive procedure and is not appropriate as the *initial* acute management for **AF with RVR**.- A stable patient requires rate control and anticoagulation first before determining the timing of the **structural intervention** (BMV).*Mitral valve replacement*- **Mitral valve replacement (MVR)** is a major surgical procedure reserved for patients with MS who fail percutaneous **balloon mitral valvuloplasty (BMV)** or have unfavorable valve morphology.- This is not indicated as the *initial* non-invasive step to manage acute **rate complications** in a symptomatic patient.*Anticoagulation alone*- Anticoagulation is essential management for MS complicated by AF (high **thromboembolism** risk) but does not address the acute physiological cause of **dyspnea and fatigue** (the rapid heart rate).- Ignoring the **rapid ventricular response** would leave the patient vulnerable to acute circulatory deterioration and continued pulmonary congestion.

Q: A 58-year-old man presents with progressive dyspnea and bilateral ankle swelling. JVP is elevated and there's a third heart sound. Chest X-ray shows pulmonary edema. What is the most likely cause of the third heart sound?

S3 gallop. ***S3 gallop*** - The presence of **dyspnea**, **bilateral ankle swelling**, **elevated JVP**, and **pulmonary edema** indicates severe **congestive heart failure (CHF)** and **volume overload**. - An **S3 gallop** is a low-frequency sound in early diastole, indicative of **ventricular volume overload** or **systolic heart failure**, resulting from rapid ventricular filling into a dilated, non-compliant ventricle. *S4 gallop* - An **S4 gallop** is a presystolic sound heard in late diastole, typically associated with **diastolic dysfunction** (e.g., in **hypertension**, **aortic stenosis**) due to atrial contraction into a stiff ventricle. - This patient's presentation with significant **pulmonary edema** and **volume overload** points more towards systolic dysfunction and an S3 rather than isolated diastolic dysfunction. *Opening snap* - An **opening snap** is a high-pitched diastolic sound characteristic of **mitral stenosis**, caused by the sudden opening of a stenotic mitral valve. - The clinical picture does not suggest primary valvular stenosis but rather global heart failure. *Ejection click* - An **ejection click** is a high-pitched systolic sound occurring shortly after S1, often related to the opening of a **stenotic semilunar valve** or a dilated great artery. - This is a systolic event, not the diastolic third heart sound described in the question. *Pericardial knock* - A **pericardial knock** is a loud, early diastolic sound heard shortly after S2, characteristic of **constrictive pericarditis**. - While associated with elevated JVP and edema, constrictive pericarditis often presents with less prominent **pulmonary edema** and may feature **Kussmaul sign**, which is not mentioned.

Q: A 62-year-old woman presents with progressive dyspnea and bilateral ankle swelling. Chest X-ray shows cardiomegaly. BNP is 2800 pg/mL. Echocardiogram shows EF 30%. What is the most appropriate first-line medication?

ACE inhibitor. ***ACE inhibitor*** - **ACE inhibitors** (or ARBs/ARNIs) are the cornerstone of **Guideline-Directed Medical Therapy (GDMT)** for **Heart Failure with reduced Ejection Fraction (HFrEF)**, demonstrating significant reduction in morbidity and mortality. - They work by blocking the **Renin-Angiotensin-Aldosterone System (RAAS)**, leading to reduced afterload and preload, and reversing detrimental cardiac remodeling. *Furosemide* - Although vital for managing the patient's acute **volume overload** (dyspnea, ankle swelling) by inducing diuresis, it is a symptomatic treatment and is not considered the first-line medication to improve long-term survival in HFrEF. - Diuretics like Furosemide must be used in conjunction with foundational **GDMT** agents (ACEi/BB/MRA) but are not the initial mortality-reducing treatment. *Beta-blocker* - Beta-blockers are a mandatory class of first-line agents in HFrEF (along with RAAS inhibitors) that reduce mortality by blocking sympathetic overactivity. - However, they are often initiated or up-titrated *after* the patient is stabilized and on an ACE inhibitor because they can worsen symptoms during acute decompensation if not dosed carefully. *Spironolactone* - This agent is a **Mineralocorticoid Receptor Antagonist (MRA)**, which confers additional mortality benefit when added to a regimen of an ACE inhibitor (or ARB/ARNI) and a beta-blocker. - It is used as part of **triple therapy** and is not the appropriate *first* medication to initiate RAAS inhibition, especially due to risks like **hyperkalemia**. *Digoxin* - Digoxin is primarily used to control symptoms (reducing hospitalizations) in patients with severe HFrEF who remain symptomatic despite optimal **GDMT**, or for rate control in coexisting **atrial fibrillation**. - It does not improve overall survival and is therefore not a first-line choice for mortality benefit in HFrEF.

Question 1

A 61-year-old man presents with progressive dyspnea and fatigue. Echocardiogram shows severe aortic stenosis with valve area $0.5\mathrm{cm}^2$. He develops syncope during exercise testing. What is the most appropriate management?

Accepted Answer

Urgent aortic valve replacement

Answer

Medical management

Answer

Balloon aortic valvuloplasty

Answer

Heart transplantation

Answer

ICD insertion

Question 2

A 57-year-old diabetic man presents with a non-healing foot ulcer for 3 months. Ankle-brachial pressure index is 0.3. What does this indicate?

Accepted Answer

Severe arterial disease

Answer

Normal arterial supply

Answer

Mild arterial disease

Answer

Moderate arterial disease

Answer

Venous disease

Question 3

A 55-year-old woman presents with progressive dyspnea and fatigue. Echocardiogram shows severe aortic regurgitation with LV end-systolic dimension 58mm and EF 48%. She is asymptomatic at rest. What is the most appropriate management?

Accepted Answer

Aortic valve replacement

Answer

Medical management

Answer

ACE inhibitors and monitoring

Answer

Exercise stress testing

Answer

Cardiac catheterization

Question 4

A 53-year-old woman presents with progressive dyspnea and fatigue. Echocardiogram shows severe mitral regurgitation with flail posterior leaflet. LV function is normal but LV end-systolic dimension is 45mm. What is the most appropriate management?

Accepted Answer

Mitral valve repair

Answer

Medical management

Answer

Mitral valve replacement

Answer

Heart transplantation

Answer

Balloon valvuloplasty

Question 5

A 46-year-old man presents with progressive dyspnea and fatigue. Echocardiogram shows severe mitral stenosis with valve area 0.7 cm². He is in atrial fibrillation with rapid ventricular response. What is the most appropriate initial management?

Accepted Answer

Rate control with digoxin

Answer

Immediate cardioversion

Answer

Balloon mitral valvuloplasty

Answer

Mitral valve replacement

Answer

Anticoagulation alone

Question 6

A 61-year-old woman presents with progressive dyspnea and bilateral ankle swelling. Echocardiogram shows severe tricuspid regurgitation. Right heart catheterization shows mean PAP 50 mmHg. What is the most likely diagnosis?

Accepted Answer

Pulmonary hypertension

Answer

Left heart failure

Answer

COPD

Answer

Pulmonary embolism

Answer

Tricuspid valve disease

Question 7

A 67-year-old man presents with progressive dyspnea and orthopnea. Chest X-ray shows cardiomegaly and Kerley B lines. BNP is 1800 pg/mL. What does BNP level indicate?

Accepted Answer

Moderate heart failure

Answer

Mild heart failure

Answer

Severe heart failure

Answer

Acute coronary syndrome

Answer

Pulmonary embolism

Question 8

A 58-year-old man presents with progressive dyspnea and bilateral ankle swelling. JVP is elevated and there's a third heart sound. Chest X-ray shows pulmonary edema. What is the most likely cause of the third heart sound?

Accepted Answer

S3 gallop

Answer

S4 gallop

Answer

Opening snap

Answer

Ejection click

Answer

Pericardial knock

Question 9

A 67-year-old man presents with progressive dyspnea and fatigue. Echocardiogram shows concentric LVH with EF 55% but impaired diastolic function. What is the most likely diagnosis?

Accepted Answer

Heart failure with preserved ejection fraction

Answer

Dilated cardiomyopathy

Answer

Hypertrophic cardiomyopathy

Answer

Restrictive cardiomyopathy

Answer

Ischemic cardiomyopathy

Question 10

A 62-year-old woman presents with progressive dyspnea and bilateral ankle swelling. Chest X-ray shows cardiomegaly. BNP is 2800 pg/mL. Echocardiogram shows EF 30%. What is the most appropriate first-line medication?

Accepted Answer

ACE inhibitor

Answer

Furosemide

Answer

Beta-blocker

Answer

Spironolactone

Answer

Digoxin

Cardiology — MCQs

Cardiology — MCQs

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