questions cardiac procedures & valvular heart diseases ronald d’agostino d.o., f.a.c.c.,...

QUESTIONS QUESTIONS CARDIAC PROCEDURES & CARDIAC PROCEDURES &

VALVULAR HEART DISEASESVALVULAR HEART DISEASES

Ronald D’Agostino D.O., F.A.C.C., F.A.C.P.Ronald D’Agostino D.O., F.A.C.C., F.A.C.P.

Director of Non-Invasive CardiologyDirector of Non-Invasive Cardiology

Long Island CardiovascularLong Island Cardiovascular

Manhasset, NYManhasset, NY

Question 1• Pharmacologic or nonpharmacologic intervention, in individuals post-MI who

are identified as high risk for death based on noninvasive risk stratification, has been determined to improve mortality in a subgroup of:

A. Patients with > 10 PVCs/hr or nonsustained VT on Holter monitor treated with amiodarone.

B. Patients with poor heart rate variability treated with beta blockers.

C. Patients with T-wave alternans treated with CABG.

D. Patients with impaired LV function, spontaneous nonsustained VT on Holter, and inducible VT at EP study treated with an ICD.

E. Patients with a positive SAECG and impaired LV function treated with CABG.

Question 2• In which patient population would invasive electrophysiologic testing

be most likely to have diagnostic utility?

A. Individuals with recurrent syncope or sinus bradycardia but no diagnostic arrhythmias on Holter monitor with normal echocardiograms.

B. Patients with recurrent syncope, isolated RBBB, left anterior bundle branch block, and no other evidence of structural heart disease on echocardiogram and physical examination.

C. Post-MI patients with LVEF < 40% and recurrent syncope.

D. Patients with long QT syndrome and recurrent syncope.

E. Patients with dilated nonischemic cardiomyopathy.

Question 3• In a patient presenting with a wide complex tachycardia, which statement is

true?

A. With a history of prior MI, ventricular tachycardia is the most likely arrhythmia.

B. The presence of 1:1 P to QRS association is diagnostic of supraventricular tachycardia with aberrancy or fixed bundle branch block.

C. A "pre-excited" tachycardia can be excluded based on morphologic characteristics of the surface ECG.

D. A QRS width less than 140msec favors the diagnosis of ventricular tachycardia.

E. AV dissociation is seen in approximately 2/3 of ECGs with ventricular tachycardia.

Question 4• All but one of the following statements about PTCA versus CABG is true.

Which one is false?

A. CABG appears superior to PTCA in treated diabetics with coronary artery disease.

B. Up to 20% of patients randomized to an initial strategy of PTCA required subsequent revascularization procedures.

C. CABG and PTCA yield similar rates of mortality and nonfatal myocardial infarction in patients with multivessel disease who are candidates for either procedure.

D. CABG results in a greater relief of angina compared with PTCA over the first year after revascularization.

E. Long-term costs of PTCA and CABG are similar.

Question 5

• You are asked for "medical clearance" for a 72-year-old man to undergo transurethral resection of the prostate for benign prostatic hypertrophy, manifested by bothersome and recurrent symptoms of urinary hesitancy and urgency. The patient has required urethral catheterization on two occasions for urinary tract obstruction.

Question 5

• Two years earlier, the patient underwent coronary surgical revascularization, with grafts placed to the left anterior descending and right coronary arteries. The revascularization was "complete" in that there were no additional vessels involved. Left ventricular function was normal preoperatively. The patient has not undergone any cardiac testing since the operation.

Question 5

• On a few occasions, the patient has experienced angina with vigorous activity, for instance when walking up a steep hill or playing golf; on each occasion, the chest discomfort resolved with rest and did not recur as the patient continued his activity. The patient is retired. He does not engage in a structured exercise program. He does golf, work in the garden and around the house, and mows his small lawn with a self-propelled, push mower.

Question 5

• At physical examination, the blood pressure is 130/80. The cardiovascular examination is normal. The ECG shows normal sinus rhythm with a normal QRS and nonspecific ST-T abnormalities.

Question 5

• With this information, you would recommend:

A. Coronary cineangiography.

B. Exercise stress test.

C. Proceed with urologic surgery.

D. Nuclear stress test.

E. Holter monitor.

Question 6

• You are called to the emergency room to evaluate a previously healthy 42-year-old Asian man who presented with progressive dyspnea on exertion for the past 6 months and the inability to sleep flat comfortably for the past two nights. When asked, he reports that he also has gained 15lbs and noted new ankle edema over the past 2 weeks. He denies any history of chest pain or known heart disease. He works as a computer programmer, is fairly sedentary, and takes no regular medications. He quit his half-pack-per-day smoking habit about a year ago. He consumes two glasses of wine per night.

Question 6

• His mother had a heart attack in her late 60s but is alive and active now in her 70s, and he has no other relevant family history.

On exam he appears moderately overweight and in mild respiratory distress, lying at 30 degrees on the gurney, but is able to speak in complete sentences. His blood pressure is 130/90, pulse 88/min and regular. He has jugular venous distension to the mandible at 30 degrees and rales over the bases of both lungfields. Cardiac exam reveals a laterally displaced PMI, a 2/6 holosystolic murmur at the left sternal border and apex, and a loud S3 gallop. The liver is mildly enlarged and pulsatile and there is pretibial edema.

Question 6

• His electrocardiogram shows sinus rhythm with mild repolarization abnormalities, but a normal axis and intervals and no pathologic Q waves. Chest radiograph shows moderate cardiomegaly and venous redistribution of the pulmonary flow. A bedside echocardiogram reveals moderate global hypokinesis of the left ventricle and 2+ mitral regurgitation.

He begins breathing much more comfortably a half hour after a dose of intravenous furosemide. He is admitted to the CCU for monitoring and it is Monday morning; his initial CPK and troponin levels are normal.

Question 6

• What diagnostic test would be most important to recommend be done next?

A. A stress echocardiogram using dobutamine.

B. A rest thallium scan.

C. Coronary arteriography.

D. Endomyocardial biopsy.

E. Serial cardiac enzymes.

Question 7•

Late potentials have been shown to give prognostic information concerning survival in patients with which of the following?

A. Sustained ventricular tachycardia.

B. Nonsustained ventricular tachycardia.

C. Recent myocardial infarction.

D. Syncope of unexplained etiology.

E. Long QT syndrome.

E. long QT syndrome.

Question 8

• A 24-year-old Indian man is seen after a syncopal episode that occurred while he was watching a football game on TV. His wife noticed that after a particularly exciting play, the patient suddenly slumped over. She shook him hard, and, after about 30 seconds, he woke up and said that he remembered nothing of the incident. This has never happened before. Up until this time, he has had no limitation of physical activity. His past medical history is significant in that he had repair of tetralogy of Fallot at age 4, at which time a VSD was patched and a right ventricular infundibulectomy was done.

Question 8

• Physical examination finds no cyanosis. Blood pressure is 100/70 mmHg, and pulse is 65 per minute with an occasional premature contraction. The lungs are clear to auscultation and percussion. Neck veins are 4cm. There is a mid sternal incision that is well healed. There is a slight precordial systolic lift. S2 is single. There is a Grade II/VI systolic ejection murmur with a short Grade II/VI diastolic low-pitched murmur along the left sternal border. There is no S3 or S4.

Question 8

• The ECG shows right bundle branch block with left anterior hemiblock. The PR interval is 0.12 seconds. The echocardiogram reveals a slightly dilated right ventricle and paradoxical motion of the interventricular septum. Doppler gradient across the right ventricular outflow tract is 35 mmHg. There is evidence of moderately severe pulmonic regurgitation, and there are no left-to-right or right-to-left shunts.

Question 8

• What is the most important diagnostic test needed for this patient?

A. TEE.

B. Electrophysiology study.

C. Cardiac catheterization and angiography.

D. Tilt table test.

E. 24-hour ambulatory ECG.

Question 9

• The Allen test is useful to confirm which of the following?

A. Occlusion of the ulnar artery.

B. Occlusion of the radial artery.

C. Occlusion of the superficial palmar arch.

D. All of the above.

E. None of the above.

Question 10

• An index population of 1,000 patients selected for the evaluation of a new test is divided, after disease verification, into subpopulations defined in terms of numbers of true positives (TP), true negatives (TN), false positives (FP), and false negatives (FN) as follows:

CAD No CAD

(+) test (-) test (+) test (-) test

600 200 40 160

TP FN FP TN

Question 10

• All of the following statements are true except:

A. Test sensitivity is 0.75, specificity is 0.80.

B. CAD prevalence is 80%, the prevalence of no disease is 20%.

C. The (+) PV for the test is 75%, the (-) PV is 55%.

D. All of the above are true.

Question 11

• A 63-year-old woman has a history of an old inferior myocardial infarction with an LV ejection fraction of 50%. She was doing well on digoxin .125 mg/day (serum digoxin level 0.8mg) and 10mg Lasix. While watching an exciting TV adventure show, she became extremely dyspneic and was brought to the hospital. A sublingual nitroglycerin made her much more comfortable.

Question 11

• On physical examination, she was slightly dyspneic, BP 140/70, pulse 85. Lung exam showed rales halfway up the chest. JVP was 6cm. Carotid pulse was normal. The apex beat was within the MCL and appeared normal. S4, S1, S2 were present with A2 > P2. A grade 1/6 systolic ejection murmur was heard along the left sternal border.

Question 11

• Of the following diagnostic choices, which one would be the most helpful at this point?

A. Electrophysiologic study with programmed stimulation.

B. Cardiac cath with coronary angiography.

C. Ventilation/perfusion lung scan.

D. Transesophageal echo.

E. Holter monitor.

Question 12

• A 39-year-old woman with a family history of CAD (father had MI at age 61) presents complaining of palpitations and shortness of breath with intermittent chest tightness. She notes this when emotionally stressed but with no particular association to exertional activity. Her primary care physician performed a standard ETT. She went 11 minutes (12 METS) and complained of sharp left-sided chest pain during peak exercise. There were no ECG changes.

Question 12

• She thought that her chest pain was similar but not exactly the same as that which prompted her to seek medical attention. Her primary care physician feels she should have further evaluation. She is thus referred to you. You find no abnormalities on physical exam.

Question 12

• Which of the following should be performed?

A. No further workup is needed.

B. Proceed with ETT-Thallium.

C. Proceed with coronary angiography.

D. Proceed with stress echo.

E. Recommend Ultrafast CT.

Question 13

• You are consulted to assess the perioperative risk for a 69-year-old man who is scheduled to undergo abdominal aortic aneurysmectomy for an asymptomatic aneurysm, the diameter of which measures 5.6cm by ultrasound.

Question 13

• The patient sustained myocardial infarction 6 months earlier. He has not undergone cardiac testing since the event. He is unable to return to work as an accountant since the infarction because he experiences angina whenever attempting to climb the one flight of stairs to his office. He can walk about his house without difficulty and can walk short distances with his wife on shopping trips. Angina prevents him from golfing, working in his lawn, or walking around his city block.

Question 13

• The patient continues to smoke 1.5 packs of cigarettes a day. He has been diagnosed with chronic obstructive pulmonary disease, and he experiences dyspnea with any moderate activity, such as walking short distances. His medications include theophylline, an inhaler, isosorbide, and diltiazem

Question 13

• Physical examination demonstrates a blood pressure of 118/58. The AP diameter of the chest is increased, and breath sounds diminished, with a prolonged expiratory phase and quiet wheeze. The heart is not palpable, and the heart sounds are quiet; no murmur is heard. The peripheral pulses are normal, and the abdominal aneurysm is neither palpable nor tender. The ECG shows left bundle branch block.

Question 13

• With this information, what would you recommend?

A. Coronary cineangiography.

B. Surgery.

C. Dobutamine stress echo.

D. Persantine thallium scintigraphy.

Question 14

• The incidence of major complication of diagnostic cardiac catheterization is:

A. Less than 0.05%.

B. Between 0.11-0.15%.

C. Between 1-2%.

D. Between 3-5%.

E. Greater than 5%.

Question 15

• Which one of the following laboratory tests is the best to determine the severity of aortic stenosis?

A. Echocardiographic demonstration of aortic valve calcification.

B. ECG evidence of left ventricular hypertrophy.

C. Doppler echo calculations using continuity equation.

D. Cardiomegaly on chest x-ray.

E. Measurement of the pressure gradient at cardiac catheterization.

Question 16• A 40-year-old woman presents with aortic regurgitation due to a

myxomatous aortic valve. She is asymptomatic and has good exercise tolerance on a treadmill test (Bruce protocol). Baseline echo reveals normal LV systolic function with an estimated ejection fraction of 65%.

Which one of the following is the most reliable method of serially following this patient's course?

A. Echocardiographic indices at rest.

B. Treadmill testing.

C. Chest x-ray.

D. Physical examination.

E. Rest and stress MUGA images.

Question 17

• An 80-year-old Asian woman awakens at 2 a.m. feeling as if she were being smothered. She is brought to the ED and is found to be in pulmonary edema. She has a history of a heart murmur, discovered 20 years before. Prior to this episode she says she was in good health, although she has not been physically active due to arthritic discomfort for the past 5 years. On careful questioning she admits to brief episodes of pressure-like sensation in her chest especially when she becomes aggravated.

Laboratory : Chest X-ray: slightly enlarged cardiac silhouette, pulmonary vascular redistribution and pulmonary edema. ECG: QS in V1, a small r in V2, a 25mm R

wave in V5 and a 30mm R wave in V6. There is 2mm ST-segment depression in

V4-6 . Echo: estimated EF 55%, first troponin <0.3 ng/ml.

The patient is given O2, Lasix, digoxin, and enalapril and becomes less dyspneic.

Her pulse decreases to 90/min and BP to 110/85 mmHg.

Question 17

• The most probable diagnosis in this case is:

A. Severe aortic regurgitation.

B. Severe valvular aortic stenosis.

C. Hypertensive cardiovascular disease.

D. Acute non-ST-elevation myocardial infarction.

E. Congestive heart failure with diastolic dysfunction

Question 18

• In following a patient with the Marfan syndrome and mild aortic and mitral regurgitation, which one of the following represents the greatest life threat?

A. Progressive mitral regurgitation.

B. Acute aortic regurgitation.

C. Subacute bacterial endocarditis.

D. Aortic dissection.

Question 19• Which one of the following statements about mitral valve prolapse is

incorrect?

A. The extent of echocardiographic thickening of the floppy mitral valve is a major determinant of long-term prognosis.

B. Clinical auscultatory phenomena as well as echocardiographic documentation should be present for the diagnosis of mitral valve prolapse.

C. Most symptoms in patients with the mitral valve prolapse syndrome are related to the severity of mitral regurgitation.

D. Echocardiographic mitral valve prolapse may be seen in normal individuals after volume depletion.

Question 20• A patient with staphylococcal septicemia develops acute aortic regurgitation

with severe heart failure. What is the best choice of treatment?

A. Antibiotics for 6 weeks and medical treatment of shock and heart failure.

B. Three weeks of antibiotics plus medical treatment of shock and heart failure with aortic valve replacement in 3 weeks.

C. Antibiotics for 1 week plus medical treatment of heart failure, followed by aortic valve replacement in 1 week.

D. Antibiotics immediately and emergency aortic valve replacement that day.

E. Intravenous nitroprusside plus antibiotics with the surgical decision to be made once the patient is stable.

Question 21

• A 25-year-old white man comes to the emergency department with acute shortness of breath for the past 12 hours. He is a known IV drug user and states that he had the onset of chills and fever 3 days ago. He is orthopneic and in obvious distress.

Question 21

• Physical examination finds blood pressure of 100/60 mmHg, pulse of 120 per minute and regular, and temperature of 39°C. There are bibasilar rales and collapsing carotid pulses. The PMI is diffuse but not beyond the mid clavicular line. S1 is soft. There is a Grade II systolic ejection murmur at the base and apex. There is a Grade I short diastolic murmur along the left sternal border, and there is a positive S3. The radial pulses are normal.

Question 21

• The chest x-ray shows pulmonary edema. The heart size is within normal limits. The ECG shows nonspecific ST-T wave changes. The echocardiogram shows left ventricular end-diastolic volume of 100 cc/m², ejection fraction of 0.50, and "moderately severe" aortic regurgitation

Question 21• Blood cultures are drawn, and antibiotics are started with 40mg IV

Lasix. The patient starts to diurese and has less shortness of breath.

What is the most important next step?

A. Immediate catheterization to evaluate hemodynamically.

B. Add an ACE inhibitor.

C. Add 5 weeks of intravenous antibiotics.

D. Prompt surgical intervention.

E. Medical management, with surgery only if the patient remains Class III.

Question 22

• In your practice, you are meticulous in prescribing antibiotic prophylaxis for the prevention of bacterial endocarditis in all patients who warrant this precaution. You always explain that, while the disease itself is uncommon, prophylaxis is felt to be effective, is inexpensive, and should be routine.

Question 22

• One of your most conscientious and compliant patients calls on a Friday afternoon to report that she had undergone a dental procedure on short notice and had neglected to take her antibiotics. She is distressed and you want both to reassure and to make the proper medical decision.

Question 22• Which of the following statements would be best?

A. "If you are feeling well at this moment, there is no cause for alarm as the symptoms of the disease begin within 1-2 hours following initial exposure to bacteria in the bloodstream."

B. "Why don't you stop at the office this afternoon; if I am unable to hear a change in your usual murmur, then I am certain you are safe."

C. "Fortunately, there is still a much greater chance of no harm even without the antibiotic and I believe you will be safe."

D. "As you can imagine, this happens all the time. What you can do is to take double your usual dose of the antibiotic immediately and you should be safe."

E. "You should come in immediately and have blood cultures drawn."

Question 23

• A 50-year-old man is referred with a murmur of aortic stenosis--an incidental finding on a routine physical examination. The patient denies cardiac symptoms.

Question 23

• The physical examination was unremarkable except for a grade IV/ VI late crescendo murmur typical of aortic stenosis and an S4 gallop. The resting ECG showed minimal ST and T changes but no voltage criteria for LVH. The Doppler echocardiogram showed a mean gradient of 60 mmHg with thickening of the ventricular walls but a normal ejection fraction. The patient underwent a Bruce protocol exercise test and quit after 5 minutes because of dyspnea. The thallium image showed no localized defect.

Question 23

• What is the most appropriate management strategy at this time?

A. Follow the patient with echocardiography every 6 months.

B. Perform a dobutamine stress echo.

C. Start enalapril.

D. Follow the patient with an exercise stress test every 6 months.

E. Recommend aortic valve replacement.

Question 24• You hear a mid-diastolic rumble at the apex and a diastolic

decrescendo blowing murmur at the left sternal border in a patient with mild dyspnea on effort. The murmurs have been present for years.

Which of these features suggests an Austin-Flint murmur rather than organic mitral stenosis?

A. Increased S1.

B. Atrial fibrillation.

C. Presystolic accentuation of rumble.

D. Blood pressure (by cuff) 160/50.

E. Opening snap.

Question 25

• A 65-year-old Caucasian man, newly retired from working as a college professor, is referred for evaluation of a heart murmur known for many years. He has received no treatment except endocarditis prophylaxis. He says he quits tennis a little sooner recently because he gets a little tired, but still gets in an hour most sessions. Physical exam reveals a healthy appearing man with blood pressure 110/75, pulse 88/regular. There are bilateral carotid bruits and slow carotid upstroke to palpation.

Cardiac exam reveals an absent A2, a grade IV systolic ejection murmur radiating to the carotids, and a sustained apex impulse. Lungs are clear and there is no jugular venous distension at 30 degrees. An echo Doppler study shows a peak aortic gradient of 80 mmHg and a valve area of 0.7 cm2 and concentric left ventricular hypertrophy with an ejection fraction of 65%.

Question 25

• Which therapeutic approach should you recommend?

A. Continue SBE prophylaxis and re-echo in 6 months.

B. Advise that he reduce his activity level.

C. Begin a low-dose diuretic.

D. Recommend aortic valve replacement based on current information.

E. Begin an ACE inhibitor.

Question 26

• All of the following are causes of aortic insufficiency except one. Which is not a cause?

A. Rheumatic valve disease with restricted leaflet motion.

B. Bicuspid aortic valve with leaflet prolapse.

C. Ischemic heart disease with leaflet restriction from a wall-motion abnormality.

D. Aortic dissection.

E. Aortic root dilatation.

Question 27

• A 42 Year old man is referred for evaluation of a systolic murmur. Your exam shows normal carotid pulses, a prominent apical impulse, an early systolic sound, and a grade III/VI mid-systolic murmur at the base. Respiration did not change the character of these auscultatory findings. After an extrasystole, the systolic murmur increased in intensity. Hand-grip did not altar the systolic murmur. Valsalva decreased the intensity of the murmur, and it returned to baseline intensity after 7 heartbeats.

Question 27

Which of the following diagnoses is most likely?

A. Congenital pulmonic stenosis.

B. Innocent murmur.

C. Mitral valve prolapse

D. Hypertrophic obstructive cardiomyopathy

E. Bi-cuspid aortic valve.

questions cardiac procedures & valvular heart diseases ronald d’agostino d.o., f.a.c.c.,...

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