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: 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 3: 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 4: 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 5: 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 Flashcard 1 of 5

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 5

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

Answer: McCallum plaques

Cardiac Pathology Flashcard 3 of 5

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 5

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 5

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

Answer: lymphocytic