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.

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

Cardiology — MCQs

Cardiology — MCQs

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