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Cardiology Board Review Cardiology Board Review Ramdas G. Pai University of California Riverside School of Medicine California, USA Padmini Varadarajan Loma Linda University Medical Center California, USA Sudha M. Pai Loma Linda University Medical Center California, USA This edition first published 2018 © 2018 John Wiley & Sons Ltd All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions. The right of Ramdas G. Pai, Padmini Varadarajan, and Sudha M. Pai to be identified as the authors of this work has been asserted in accordance with law. 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Library of Congress Cataloging-in-Publication Data: Names: Pai, Ramdas G., author. | Varadarajan, Padmini, author. | Pai, Sudha M., 1958- author. Title: Cardiology board review / by Ramdas G. Pai, Padmini Varadarajan, Sudha M. Pai. Description: Hoboken, NJ : Wiley, 2017. | Includes index. | Identifiers: LCCN 2017026562 (print) | LCCN 2017028086 (ebook) | ISBN 9781118699003 (pdf ) | ISBN 9781118699010 (epub) | ISBN 9781118699027 (pbk.) Subjects: | MESH: Heart Diseases | Examination Questions Classification: LCC RC669.2 (ebook) | LCC RC669.2 (print) | NLM WG 18.2 | DDC 616.1/20076–dc23 LC record available at https://lccn.loc.gov/2017026562 Cover images: inset – © RichHobson/Gettyimages; main – © asiseeit/Gettyimages Cover design by Wiley Set in 10/12pt WarnockPro by Aptara Inc., New Delhi, India 10 9 8 7 6 5 4 3 2 1 Contents Preface ix 1 History and Physical Examination Ramdas G. Pai Electrocardiography 13 Ramdas G. Pai and Sudha M. Pai Chest X-Ray in Cardiology 51 Padmini Varadarajan and Ramdas G. Pai Stress Testing and Risk Stratiﬁcation of Asymptomatic Subjects Padmini Varadarajan and Ramdas G. Pai Echocardiography 95 Ramdas G. Pai and Padmini Varadarajan Cardiac Magnetic Resonance Imaging Padmini Varadarajan and Ramdas G. Pai Cardiac Computed Tomography Ramdas G. Pai Cardiac Catheterization Prabhdeep S. Sethi Acute Coronary Syndromes 210 Ramdas G. Pai Chronic Coronary Artery Disease Padmini Varadarajan Heart Failure, Transplant, Left Ventricular Assist Devices, Pulmonary Hypertension 245 Ramdas G. Pai Cardiomyopathies 270 Ramdas G. Pai and Padmini Varadarajan 80 150 172 199 229 vi Contents Hypertension 288 Padmini Varadarajan and Ramdas G. Pai Diabetes Mellitus 298 Padmini Varadarajan Lipids 305 Padmini Varadarajan and Ramdas G. Pai Valvular Heart Disease 318 Ramdas G. Pai Adult Congenital Heart Disease 351 Padmini Varadarajan and Ramdas G. Pai Pericardial Diseases Ramdas G. Pai Aortic Diseases 385 Ahmed Shafter and Ashish Mukherjee Carotid and Vertebral Artery Disease 403 Prabhdeep S. Sethi Peripheral Vascular Disease 416 Ahmed Shafter and Ashish Mukherjee Cardiac Arrhythmias 435 Sudha M. Pai Pacemakers and Deﬁbrillators Sudha M. Pai Cardiac Masses 468 Padmini Varadarajan Systemic Disorders Aﬀecting the Heart Ramdas G. Pai Interdisciplinary Consultative Cardiology Ramdas G. Pai Heart Disease and Pregnancy 515 Padmini Varadarajan and Ramdas G. Pai Racial and Gender Disparities 521 Sudha M. Pai and Ramdas G. Pai 376 463 501 505 Contents Pharmacological Principles of Cardiac Drugs Christopher Hauschild and Lily Yam Anticoagulation 535 Padmini Varadarajan Aspirin and Antiplatelet Therapy 547 Christopher Hauschild and Lily Yam Statistical Concepts 553 Ramdas G. Pai Genetics 562 Padmini Varadarajan Cardiac Emergencies and Resuscitation 565 Ramdas G. Pai Index 571 524 vii Preface This book is a very comprehensive review of all major topics in cardiology with an intention to help those preparing for initial and recertification exams in cardiology and those who want to review cardiology in an easy-to-do fashion. It is a compilation of over 1300 questions encompassing all the topics in cardiology. This has been edited by an internationally acclaimed teaching physician with an expertise in all aspects of cardiology. The book is organized in a question-and-answer format and is divided into easy-tofollow chapters related to different areas of cardiovascular medicine. The answers are explained in detail and are accompanied by references to major trials in cardiology and guidelines, and some clinical pearls where applicable. The explanations are clear and evidence based. The book highlights a special section on electrocardiograms which are of high resolution. The answers to the questions are given in depth, which will allow the examinees to prepare for this section and take the exam with greater confidence as this section is scored separately from the main exam. The chapters on imaging have questions relating to chest X-ray, cardiac computed tomography, echo, stress echo, cardiac magnetic resonance imaging, nuclear stress testing, and so on. The book also deals with questions relating to topics not usually encountered in similar books: for example, racial disparities in medicine, cardiac emergencies, and so on. The book also facilitates critical review of cardiovascular medicine to enhance one’s diagnostic and therapeutic skills. History and Physical Examination .. A 25-year-old woman has a 2/6 ejection systolic murmur best heard in the second left intercostal space with normal S1. The S2 is split during inspiration, and P2 intensity is normal. No apical or parasternal heave. The murmur diminishes during expiration and standing up. What is the murmur likely due to? A. Physiological or normal B. Atrial septal defect (ASD) C. Bicuspid aortic valve D. Hypertrophic obstructive cardiomyopathy (HOCM) .. A 29-year-old pregnant woman was found to a have a systolic murmur best heard in the second left intercostal space. It is rough and there was a palpable thrill in the same area and in the suprasternal notch. Patient is asymptomatic and has normal exercise tolerance. What is the likely explanation of the murmur? A. Pulmonary stenosis (PS) B. Normal flow murmur due to increased cardiac output C. Posterior mitral leaflet prolapse causing an interiorly directed jet D. Mammary soufflé .. A 22-year-old patient has a hypoplastic radial side of the forearm and fingerized thumb. What this may be associated with? A. ASD C. Coarctation of aorta B. Tetralogy of Fallot D. Ebstein’s anomaly .. A 28-year-old man presented with a history of shortness of breath on exertion. On examination, the pulse rate was 76 bpm and blood pressure (BP) 126/80 mmHg. The left ventricular apex was prominent and forceful. The S1 and S2 were normal, but there was a 2/6 ejection systolic murmur best heard in the third right intercostal space. There was no appreciable variation with respiration, but there was an increase in intensity with the Valsalva maneuver and standing up. It seemed to be less prominent on squatting. There was no audible click. What is the murmur likely due to? A. Valvular aortic stenosis C. Mitral valve prolapse (MVP) B. HOCM D. Innocent murmur .. A 36-year-old asymptomatic woman was found to have a systolic murmur best heard in the apex, but also in the aortic area. It was mid to late systolic and was associated with a sharp systolic sound. What is the likely cause of the murmur? A. Posterior mitral leaflet prolapse C. Valvular aortic stenosis B. Anterior mitral leaflet prolapse D. Aortic subvalvular membrane .. A 78-year-old man with hypertension and diabetes mellitus presented with exertional shortness of breath of 6 months’ duration. Examination revealed a 4/6 crescendo–decrescendo murmur best heard in the second right intercostal space. Cardiology Board Review, First Edition. Ramdas G. Pai, Padmini Varadarajan and Sudha M. Pai. © 2018 John Wiley & Sons, Ltd. Published 2018 by John Wiley & Sons, Ltd. Chapter 1 Cardiology Board Review The first component of the second sound was soft. The murmur was also heard along the right carotid artery. What is this patient likely to have? A. Mild aortic stenosis C. Pulmonary stenosis B. Moderate or severe aortic stenosis D. MR .. A thrill and a continuous machinery murmur in the left infraclavicular area is indicative of what? A. Patent ductus arteriosus (PDA) B. Increased flow due to left arm arteriovenous (AV) fistula for dialysis C. Venous hum D. Pulmonary AV fistula .. Which of the following is not a feature of aortic coarctation? A. A continuous murmur on the back B. Lower blood pressure in legs compared with arm C. Radiofemoral delay D. Pistol shot sounds on femoral arteries .. A 22-year-old newly immigrant woman was referred to high-risk pregnancy clinic because of clubbing and cyanosis. Examination in addition revealed a parasternal heave, 4/6 ejection systolic murmur in the third left intercostal space, normal jugular venous pressure (JVP), and oxygen saturation of 75%. What will you recommend after confirmation of the diagnosis? A. Continue pregnancy with sodium restriction B. Continue pregnancy, but deliver at 28 weeks C. Advise termination of pregnancy D. Perform percutaneous ASD closure and continue pregnancy .. What is the murmur of ASD? A. Continuous due to flow across the defect B. Ejection systolic due to increased flow across the pulmonary valve C. Mid-diastolic due to increased flow across the tricuspid valve D. Continuous over lung fields due to increased flow in lungs .. What is a systolic click that disappears on inspiration likely due to? A. Pulmonary valvular stenosis C. MVP B. Bicuspid aortic valve D. Pulmonary hypertension .. A 36-year-old woman presented with an 8-month history of progressive exertional dyspnea. Physical examination revealed heart rate of 74 bpm, regular, BP 126/78 mmHg, no pedal edema. JVP and carotid upstroke were normal. Cardiac auscultation revealed normal S1, an accentuated P2 with narrow splitting of S2, an ejection click, and a 2/6 ejection systolic murmur. What is the likely diagnosis? A. Pulmonary hypertension C. Aortic stenosis B. PS D. ASD .. Causes of prominent “a” wave in jugular venous pulsations include all of the following except which option? A. PS D. Aortic stenosis B. Pulmonary hypertension E. ASD C. Tricuspid stenosis 1 History and Physical Examination .. What is a 6-year-old Amish boy in Pennsylvania with short stature, polydactyly, Chapter 1 short limbs, absent upper incisor teeth with dysplasia of other teeth, and a systolic murmur most likely to have? A. ASD C. Aortic coarctation B. Ventricular septal defect D. PS .. Which of the following describes ventricular septal defect murmur? A. Holosystolic C. Systolico-diastolic B. Ejection systolic D. None of the above .. Clubbing and cyanosis in lower limbs, but not upper limbs, is indicative of which of the following? A. PDA with coarctation of aorta B. PDA with pulmonary hypertension C. Ventricular septal defect Eisenmenger’s D. ASD Eisenmenger’s with coarctation of aorta .. A 46-year-old man presented with progressive fatigue and leg swelling. He had no significant past medical history except a front-on collision in a car he was driving. Examination revealed 2+ edema, raised JVP, and an enlarged liver, which seemed to expand during systole. What is the likely diagnosis? A. Severe tricuspid stenosis C. Constrictive pericarditis B. Severe tricuspid regurgitation (TR) D. Restrictive cardiomyopathy .. A 23-year-old has a mid-diastolic rumble and sharp early diastolic sound. What is the likely explanation? A. Mitral stenosis C. Restriction B. Constriction D. Bicuspid aortic valve .. A 28-year-old man has history of progressive fatigue and exertional shortness of breath over the last 6 months. Examination revealed raised JVP that seemed to increase with inspiration and a sharp precordial sound in early diastole. What is the most likely diagnosis? A. Right ventricular infarct C. Constrictive pericarditis B. Tricuspid stenosis D. Restrictive cardiomyopathy .. A 66-year-old woman with left breast cancer post mastectomy, radiation, and chemotherapy was admitted with shortness of breath, heart rate of 120 bpm, and BP of 90/60 mmHg. On slow cuff deflation during BP measurement, Korotkoff ’s sounds started at 90 mmHg during expiration only and throughout the respiratory cycle at a cuff pressure of 70 mmHg. An echocardiogram was obtained. What is this likely to show? A. Akinesis of left anterior descending area B. Thick pericardium C. Large pericardial effusion D. Large, globally hypokinetic left ventricle. .. Features of restrictive cardiomyopathy may include all of the following except which option? A. Raised JVP B. Loud S3 C. Kussmaul’s sign D. A diastolic knock in pulmonary area Chapter 1 Cardiology Board Review .. Pulsus paradoxus despite tamponade may not be present in which of the following? A. ASD C. Mitral stenosis B. Aortic stenosis D. Old age .. Pulsus paradoxus may occur in all of the following except which option? A. Tamponade C. Pulmonary embolism B. Status asthmaticus D. Aortic stenosis .. Square sign during Valsalva maneuver occurs in which of the following? A. HOCM C. Aortic stenosis B. MVP D. Congestive heart failure .. An abnormal Schamroth’s test may be found in all of the following except which option? A. Tetralogy of Fallot C. Left atrial myxoma B. Subacute bacterial endocarditis D. Aortic stenosis 1.26–1.31. For the jugular vein or RA pressure tracings shown in Figures 1.26–1.31, match with an appropriate clinical scenario from the following choices: Q26 mmHg 10 Q29 mmHg 10 5 5 0 0 Q27 mmHg 10 Q30 mmHg 10 5 5 0 0 Q28 mmHg 10 Q31 mmHg (mean) 10 5 5 0 0 Figures .–. Inspiration 1 History and Physical Examination A. B. C. D. E. Normal Pericardial constriction Restrictive cardiomyopathy ASD Tricuspid stenosis F. TR Chapter 1 G. Cardiac tamponade H. Superior vena cava syndrome I. Heart failure J. PS 1.32–1.37. For the jugular vein or RA pressure tracings shown in Figures 1.32–1.37, match with an appropriate clinical scenario from the following choices: A. Normal G. Cardiac tamponade B. Pericardial constriction H. Superior vena cava syndrome C. Restrictive cardiomyopathy I. Heart failure D. ASD J. PS E. Tricuspid stenosis K. Complete heart block F. TR Q32 Q35 mmHg 10 mmHg (mean) 10 Inspiration 5 5 0 0 Q33 mmHg 10 a v a v Q36 mmHg (mean) 20 5 10 0 0 Q34 mmHg 10 Inspiration Q37 mmHg (mean) 20 5 10 0 0 Inspiration Figures .–. 1.38–1.45. For the carotid pulse or arterial pressure tracings shown in Figures 1.38– 1.45, match with an appropriate clinical scenario from the following choices: A. Normal H. HOCM B. Constriction I. Heart failure C. Aortic stenosis J. Complete heart block D. AR K. MR E. Mitral stenosis L. Premature ventricular contraction F. Mixed aortic stenosis and AR (PVC) G. Cardiac tamponade Chapter 1 Cardiology Board Review Q38 mmHg 120 80 Q39 mmHg 120 80 Q42 mmHg 120 80 Q43 mmHg 120 80 Inspiration Q40 mmHg 120 80 Q41 mmHg 120 80 Q44 mmHg 120 80 Q45 mmHg 120 80 Figures .–. Answers .. A. Physiological or normal. The murmur is <3/6 in intensity and diminishes with standing, when venous return is less, indicating a flow murmur. S2 split during inspiration only is physiological. During inspiration, increased venous return and pulmonary flow prolongs right ventricular (RV) ejection. This delays P2. .. A. Pulmonary stenosis (PS). A murmur associated with a thrill indicates that it is pathological and not just due to increased cardiac output. A thrill in the suprasternal notch is pathognomonic of PS. Valvular PS would be associated with an ejection click which diminishes with inspiration. Left parasternal heave would be indicative of RV hypertrophy (RVH). 1 History and Physical Examination .. A. ASD. Chapter 1 The features are suggestive of Holt–Oram syndrome. .. B. HOCM. In HOCM, the left ventricular (LV) outflow obstruction is dynamic and is increased by an increase in LV contractility or a reduction in LV size. Standing, Valsalva maneuver, and amyl nitrite reduce venous return, reduce LV filling, and increase systolic anterior motion of the anterior mitral leaflet (SAM), resulting in increased LV outflow tract (LVOT) obstruction. Squatting kinks leg arteries, raising peripheral resistance and hence an increase in LV volume. This reduces SAM and LV outflow obstruction. Valvular aortic stenosis murmur intensity is flow dependent, and hence reduction in venous return with standing or Valsalva maneuver as well as increase in peripheral resistance with squatting would diminish the murmur. In mitral valve prolapse (MVP), an increase in LV volume would reduce prolapse, and a reduction in LV volume would lengthen the murmur by producing earlier prolapse. MVP is generally associated with a mid-systolic click. .. A. Posterior mitral leaflet prolapse. The systolic click and late systolic murmur indicate MVP. In anterior leaflet prolapse, the mitral regurgitation (MR) jet is directed posteriorly and murmur may be conducted to the axilla. In posterior leaflet prolapse, the jet is anterior wall hugging, along the aortic root, which facilitates its conduction to the aortic area. .. B. Moderate or severe aortic stenosis. This is a classic aortic stenosis murmur with carotid conduction. Soft A2 (first component of S2 indicates significant aortic stenosis). Features of severe aortic stenosis are late-peaking murmur, absent A2, paradoxic splitting of S2 (i.e. split during expiration instead of inspiration), and slow-rising carotid pulse (pulsus parvus et tardus). .. A. Patent ductus arteriosus (PDA). Though the other conditions can produce continuous murmurs, they are not associated with a thrill or machinery character. .. D. Pistol shot sounds on femoral arteries. Pistol shot sounds occur in severe aortic regurgitation (AR). Others are features of aortic coarctation. .. C. Advise termination of pregnancy. The findings are typical of tetralogy of Fallot, and the murmur is due to PS. Murmur of ASD is due to flow and softer and not associated with clubbing or cyanosis unless associated with Eisenmenger’s syndrome. Tetralogy of Fallot is associated with extremely high risk, and pregnancy should be terminated. .. B. Ejection systolic due to increased flow across the pulmonary valve. Flow across the defect and the lungs does not produce murmurs. It takes a torrential shunt to produce a mid-diastolic flow murmur across the tricuspid valve. .. A. Pulmonary valvular stenosis. In severe PS, due to low pulmonary artery (PA) pressure, an increase in venous return to right ventricle during inspiration may open the pulmonary valve before systole, eliminating the ejection click. Chapter 1 Cardiology Board Review .. A. Pulmonary hypertension. This is suggested by loud P2. In pulmonary hypertension, P2 moves closer to A2 due to higher pulmonary valve closure pressure, and S2 may be single when PA pressure approaches systemic pressure. Ejection click and soft ejection systolic murmur may occur because of PA dilation. Other features of pulmonary hypertension may include a palpable PA in second left intercostal space, a palpable P2 or diastolic knock, parasternal heave due to RVH and prominent “a” wave in jugular venous pulsation due to RVH resulting in accentuated right atrial (RA) systole. PS results in a louder murmur and diminished P2. ASD results in wide, fixed, splitting of S2. .. E. ASD. Prominent “a” wave occurs due to forceful RA systole, and this can occur against stenotic tricuspid valve, hypertrophied RV (PS and pulmonary hypertension) or hypertrophied ventricular septum (aortic stenosis, hypertrophic cardiomyopathy, or hypertension). In ASD, defect in the atrial septum would not allow a prominent “a” wave, even in the presence of pulmonary hypertension, as the right atrium would decompress into the left atrium during atrial systole. .. A. ASD. ASD or common atrium as part of Ellis–van Creveld syndrome or mesoectodermal or chondroectodermal dysplasia is an autosomal recessive inheritance disorder that occurs in old-order Amish population. The EVC gene is on chromosome number 4, short arm. It is a form of ciliopathy. Other ciliopathies that result in abnormal organogenesis include Bardet–Biedl syndrome, polycystic kidney and liver disease, Alstrom syndrome, Meckel–Gruber syndrome, and some forms of retinal degeneration, and so on. .. A. Holosystolic. .. B. PDA with pulmonary hypertension. In PDA Eisenmenger’s, the shunt reversal through PDA causes desaturation in lower part of the body only, resulting in central cyanosis and clubbing in lower extremities and not upper extremities. .. B. Severe tricuspid regurgitation (TR). Liver that is pulsatile (expansile) in systole is indicative of a powerful RA “V” wave, and this suggests severe TR. This can also be seen in the jugular venous pulsation. Sternal compression during the motor vehicle accident likely caused a flail tricuspid valve and severe TR. Liver pulsation in tricuspid stenosis is pre-systolic. Liver pulsations are not seen in constriction or restriction. .. A. Mitral stenosis. This is typical mitral stenosis with pliable leaflets, which causes opening snap. A2-OS interval is a good measure of mitral stenosis severity. Normally, 70–100 ms (same as isovolumetric relaxation time). Less than 70 ms indicates high left atrial pressure, suggesting severe mitral stenosis. .. C. Constrictive pericarditis. Rise in JVP is paradoxical (Kussmaul’s sign), and sharp protodiastolic sound is pericardial knock – classic features of constriction. Kussmaul’s sign occurs because of lack of transmission of negative intrathoracic pressure to the right atrium 1 History and Physical Examination .. .. .. .. through the rigid pericardium. Hence, increased venous return during inspiration Chapter 1 causes a rise in RA pressure. In tricuspid stenosis, inspiratory increase in venous return may not readily empty into right ventricle, causing a paradoxical rise in JVP with inspiration. Kussmaul’s sign can occur in RV infarct but occurs in the setting of inferior myocardial infarction. Restrictive cardiomyopathy may be associated with S3, which is less sharp (a thud), but no venous paradox. C. Large pericardial effusion. This is typical cardiac tamponade with classic paradoxic pulse, hypotension, and tachycardia. Constriction causes venous paradox. C. Kussmaul’s sign. As pericardium is normal, inspiratory negative intrathoracic pressure is transmitted to cardiac chambers, and hence the venous paradox does not occur. Diastolic knock is palpable loud P2, a feature of pulmonary hypertension that is common in restrictive LV physiology. A. ASD. Pulsus paradoxus may not be present when LV filling is not affected by phase of inspiration due to lack of interventricular dependence, as in ASD, or LV filling from other sources, such as severe AR or MR. D. Aortic stenosis. .. D. Congestive heart failure. See explanation in Box 1.1 Clinical Pearls. This is because though a Valsalva maneuver reduces left-sided venous return, it does not affect LV stroke volume as it is already well filled and beyond the peak of Starling’s curve. Increase in intrathoracic pressure is transmitted to the aorta, causing an increase in aortic pressure. .. D. Aortic stenosis. This test is named after South African cardiologist for diagnosis of clubbing. In clubbing, the angle between the nail and nail fold is >165◦ and when nails of fingers from two sides are apposed, the gap between them disappears. Clubbing is seen in cardiac conditions (in addition to a variety of pulmonary diseases) in subacute bacterial endocarditis, congenital cyanotic heart diseases, and left atrial myxoma. .. A. Normal. Note the mean RA pressure of <5 mmHg and the “a” wave due to atrial systole is slightly higher than the “V” wave, which occurs because of RA filling on the closed tricuspid valve. A smaller “V” wave indicates a compliant right atrium. The sharp “C” wave that coincides with the QRS complex of the electrocardiogram is due to a combination of tricuspid valve closure and transmitted carotid impulse. .. E. Tricuspid stenosis. Note the large “a” wave as the RA contracts against a stenosed tricuspid valve; the gradient is reflected as large “a” wave. Note that the mean RA pressure is slightly elevated as well commensurate with transtricuspid gradient. In conditions causing RVH (pulmonary hypertension, PS, aortic stenosis with septal hypertrophy), the “a” wave may be prominent due to noncompliant RV (RV fourth heart sound), but mean RA pressure may not be high unless there is heart failure. Chapter 1 Cardiology Board Review .. B. Pericardial constriction. Note elevated RA pressure with rapid “Y” descent. .. D. ASD. In ASD, the “a” and “V” waves would be of similar height because the defect leads to equilibration of the LA and RA pressures. .. F. TR. Large “V” wave is due to TR filling up RA during systole. When the “V” wave pressure is about 25–30 mmHg, it may become palpable to the examining finger and associated with expansile liver. .. B. Pericardial constriction. The increasing mean RA pressure with inspiration is the venous paradox or Kussmaul’s sign. This is because of dissociation between intrathoracic and intrapericardial pressures because of thick pericardium. During inspiration, the intrathoracic pressure drops, increasing venous return to the right atrium, but the intrapericardial and intra-RA pressure does not drop and returning blood increases the pressure further. Kussmaul’s sign can occur even in acute pericarditis and RV infarcts, the latter invoking pericardial restraint. .. J. PS. Note a large “a” wave with near-normal mean RA pressure. Contrast this with tricuspid stenosis. .. G. Cardiac tamponade. Note the raised RA pressure with prominent “X” and “Y” troughs. .. K. Complete heart block. The intermittent large waves are “cannon a” waves when atria and ventricles happen to contract simultaneously due to AV dissociation. .. A. Normal. The RA pressure is <5 mmHg and drops with inspiration. .. H. Superior vena cava syndrome. Note the high JVP which does not drop on inspiration as superior vena cava is blocked and jugular vein is not in communication with right atrial hemodynamics or pulsatile changes. In contrast to constriction, the JVP in superior vena cava syndrome is nonpulsatile. It would be high in both. .. I. Heart failure. High JVP that drops with inspiration. .. A. Normal. This is the typical normal tracing. Note the fairly rapid upstroke, pulse pressure of about 40 mmHg, dicrotic notch and dicrotic wave. .. C. Aortic stenosis. Note the very slow rise, attributable to high blood flow velocity across the valve which converts pressure to kinetic energy. .. D. AR. Note rapid upstroke, rapid downstroke (water-hammer pulse), wide pulse pressure, and low diastolic pressure due to peripheral vasodilation. This can also occur in PDA and large AV fistulae. 1 History and Physical Examination .. F. Mixed aortic stenosis and AR. Chapter 1 This is called pulsus bisferiens or double pulse. Can also occur in HOCM. .. I. Heart failure. This is pulsus alternans. Alternating strong and weak pulse with regular RR interval due to alternating stronger and weaker myocardial contraction with every other beat attributable to altered calcium handling by contractile proteins. It is a sign of severe systolic dysfunction. .. G. Cardiac tamponade. BP drop with inspiration is called pulsus paradoxus. An inspiratory drop of >10 mmHg may indicate tamponade. .. L. Premature ventricular contraction (PVC). With appropriate increase in pulse pressure in the post PVC beat due to a combination of increased preload due to long filling period and increased contractility due to force–frequency relationship. .. H. HOCM. In this patient, after PVC, instead of an augmented pulse there is a smaller pulse volume. This is due to the fact that increased contractility in the post PVC beat increases dynamic LVOT obstruction and reduces stroke volume. This is called Brockenbrough phenomenon on cardiac catheterization. This contrasts with valvular aortic stenosis, where pulse pressure increases after a PVC. Box . r r r r r r r r Clinical Pearls Loud S1 occurs when mitral valve closes forcefully from open position against transmitral gradient or prematurely and occurs in mitral stenosis, short pulmonary regurgitation (PR) interval, and hyperdynamic circulation. S1 is soft in MR, long PR interval, and severe AR. In severe AR, mitral valve may move toward closure in presystole. P2 can be loud in pulmonary hypertension (higher pulmonary valve closure sound) and dilated PA (better P2 transmission). S2 may be paradoxically split when aortic valve closure is delayed and comes after P2 as in left bundle branch block, severe aortic stenosis, severe LV dysfunction, PDA (increased transaortic flow). S2 is split in expiration and not in inspiration when RV filling and ejection time are increased. Only right-sided sound/murmur that is attenuated by inspiration is pulmonary ejection click of valvular PS as inspiratory increase in venous return to right ventricle in the presence of RVH may cause an increase on RV end diastolic pressure high enough to open the pulmonary valve as PA pressure is lower. Carey Coombs murmur is mid-diastolic mitral murmur due to mitral valvulitis in rheumatic fever. Austin Flint murmur is mitral mid-diastolic murmur heard in severe AR. Potential explanations include: AR jet causing anterior mitral leaflet vibration, or mitral/AR jet interaction or AR jet causing partial diastolic closure of anterior mitral leaflet. Graham Steel murmur is early diastolic murmur of PR that occurs in severe pulmonary hypertension. Higher PA diastolic pressure causes turbulence of PR jet and the murmur. Chapter 1 Cardiology Board Review r r r r r r r r r r Mid-diastolic murmur of mitral stenosis is best heard with the bell without much pressure as it is a low-frequency murmur and better heard in left lateral position. Presystolic accentuation indicates atrial contraction. Tapping apex typically occurs in mitral stenosis and it is palpable S1. Maneuvers are helpful in evaluating murmurs. Inspiration increases right-sided venous return and augments right-sided murmurs. Standing reduces venous return and after three or four beats LV filling as well reduces its size. This may augment HOCM murmur and lengthen MR murmur of MVP. Squatting kinks limb arteries and increases afterload. This may reduce murmurs of valvular aortic stenosis through reduced stroke volume and HOCM murmur through an increase in LV volume and shorten murmur of MVP through increasing LV volume and reducing prolapse. The Valsalva maneuver involves expiration against a closed glottis, increasing the intrathoracic pressure. There are four phases of heart rate and BP response. Normal response includes the following: – Phase 1. Early during the Valsalva maneuver, pressure on the intrathoracic aorta and pulmonary veins emptying into left heart transiently increases filling, stroke volume, and BP with reflex slowing of heart. – Phase 2. With a continued Valsalva maneuver, LV filling diminishes and lowers stroke volume and BP, resulting in compensatory tachycardia. Reflex peripheral vasoconstriction slowly increases BP and lowers heart rate. – Phase 3. With release of the Valsalva maneuver, pressure on the aorta drops, and BP drops with some increase in heart rate. – Phase 4. Left ventricle fills, with increase in stroke volume with continued peripheral vasoconstriction causing BP to overshoot the baseline value. This will reflexly reduce heart rate below baseline. Phase 2 is used in dynamic auscultation. In HOCM, the Valsalva maneuver results in smaller left ventricle size causing increased LVOT obstruction and an increase in murmur intensity. In MVP, reduced LV volume with phase 2 Valsalva results in earlier and greater prolapse and the MR murmur lengthens. Heaving apex denotes LV hypertrophy, forceful apical lift signifies LV volume overload, tapping apex loud S1, and bifid apex with presystolic lift LV occurs due to a combination of LVH with a forceful atrial kick causing S4 as it occurs in hypertrophic cardiomyopathy. Left parasternal or precordial bulge indicates RVH occurring before the rib cage ossified (young age), and parasternal lift or heave indicates RVH starting after childhood. A downward tug on larynx held up with fingers after deglutition indicates aortic arch aneurysm. Also called tracheal tug or Oliver’s sign, occurs with every heartbeat. A large, sharp systolic wave in jugular venous pulsation during systole is the cannon wave. This occurs when the right atrium contracts over closed tricuspid valve, as in complete heart block (intermittent) or junctional or idioventricular rhythm with retrograde ventriculoatrial conduction. Electrocardiography ECG diagnostic criteria are listed in Box 2.1. For the tracings in the questions/figures in this section, please analyze carefully and list the important findings and possible clinical setting. Answers are found at the end of the chapter. Question/Figure . Question/Figure . Cardiology Board Review, First Edition. Ramdas G. Pai, Padmini Varadarajan and Sudha M. Pai. © 2018 John Wiley & Sons, Ltd. Published 2018 by John Wiley & Sons, Ltd. Cardiology Board Review Chapter 2 Question/Figure . Question/Figure . 2 Electrocardiography Chapter 2 Question/Figure . Question/Figure . Cardiology Board Review Chapter 2 Question/Figure . 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Question/Figure . 2 Electrocardiography Chapter 2 Question/Figure . Question/Figure . Cardiology Board Review Chapter 2 Question/Figure . Question/Figure . 2 Electrocardiography Chapter 2 Question/Figure . Question/Figure . Cardiology Board Review Chapter 2 Question/Figure . Question/Figure . 2 Electrocardiography Chapter 2 Question/Figure . Question/Figure . Cardiology Board Review Chapter 2 Question/Figure . Question/Figure . 2 Electrocardiography Chapter 2 Question/Figure . Question/Figure . Cardiology Board Review Chapter 2 Question/Figure . Question/Figure . 2 Electrocardiography Chapter 2 Question/Figure . Question/Figure . Cardiology Board Review Chapter 2 Question/Figure . Question/Figure . 2 Electrocardiography Chapter 2 Question/Figure . Question/Figure . Question/Figure . Cardiology Board Review Chapter 2 Question/Figure . Question/Figure . Question/Figure . 2 Electrocardiography Chapter 2 Question/Figure . Question/Figure . Question/Figure . Cardiology Board Review Chapter 2 Question/Figure . Question/Figure . Answers .. Second-degree atrioventricular (AV) block, Mobitz type I (AV Wenckebach). Note increasing PR interval and PR interval being the shortest after a dropped beat. Also, note that the patient has intraventricular conduction delay (IVCD) and lateral T wave inversion. Despite IVCD, it is less likely to be trifascicular block as AV Wenckebach is generally a nodal rather than infra-Hisian phenomenon. .. Right ventricular (RV) hypertrophy (RVH) with strain and biatrial enlargement. R in V1 >5 mm with right axis deviation and ST–T changes in right chest leads support RVH. P wave amplitude >3 mm supports right atrial enlargement and P-terminale in V1 > 1 × 1 box supports left atrial enlargement. 2 Electrocardiography .. Sinus rhythm with bifascicular block. Note right bundle branch block (RBBB) and left axis deviation with mean QRS axis less than −30◦ suggesting left anterior fascicular block (LAHB). Also note that the peak of R wave is earliest in III, followed Chapter 2 by II, and then I, indicating late activation of left ventricular (LV) lateral wall supplied by anterior fascicle. Inferior wall is supplied by posterior fascicle and R wave peaks early in these leads. .. Sinus arrhythmia with short PR interval suggesting Lown–Ganong–Levine syndrome. Note that there is no delta wave or QRS prolongation indicating Wolff–Parkinson–White (WPW) syndrome. In Lown–Ganong–Levine syndrome, the accessory pathway is atrio-Hisian, shortening the PR interval. In WPW syndrome, AV preexcitation of a portion of ventricular myocardium results in delta wave and QRS prolongation. .. Atrial fibrillation. Note absence of P wave and irregularly irregular ventricular response. Also note low QRS voltage (<5 mm in limb and <10 mm in chest leads), which should raise the suspicion of chronic obstructive pulmonary disease, pericardial effusion, or diffuse myocardial disease. .. Acute anterior ST elevation myocardial infarction (STEMI). Note hyperacute, tombstone ST elevation in V2 and V3. .. Hyperkalemia. Note peaked, tall T waves in V2 and V3. .. Junctional tachycardia. P waves are inverted in inferior leads with superior axis indicating junctional or low atrial origin. .. RVH. qR in V1 with right axis deviation and strain pattern in right chest leads is suggestive of RVH. .. WPW syndrome (? posteroseptal). .. Seven beats of accelerated idioventricular rhythm, followed by a fusion beat and then accelerated junctional rhythm. This is suggestive of digoxin toxicity. .. Atrial flutter with 2 : 1 conduction. Flutter waves are clearly visible in inferior leads. .. Posterior myocardial infarction. Note tall R waves in V1 and V2 with upright T wave associated with Q waves inferolaterally. In RVH, one would expect to see strain pattern in right chest leads. .. Ventricular tachycardia. Broad complexed tachycardia with RBBB morphology with left rabbit ear, QRS duration of 200 ms and indeterminate axis – all suggestive of ventricular tachycardia (VT) rather that supraventricular tachycardia (SVT) with aberrancy. .. Atypical atrial flutter with 3 : 1 conduction, intermittent RV pacing (third and last three beats) and one fusion complex (fifth beat). .. Acute anterior STEMI. Note Q waves and ST elevation of 3–4 mm in V1 and V2. .. Sinus rhythm with low QRS voltage (<5 mm in limb leads or <10 mm in chest leads). Consider pericardial effusion, emphysema. .. Nonconducted P (second from right) followed by a P associated with a ventricular escape beat showing T wave inversion. Consistent with Mobitz type II AV block. Also note anterior Q wave, RBBB and LAFB – a substrate for trifascicular block. Cardiology Board Review .. Atrial fibrillation with rapid ventricular response. Also note low QRS voltage and diffuse ST elevation, suggesting pericarditis with effusion which may result in atrial fibrillation through atrial irritation. Chapter 2 .. Acute pericarditis. Note diffuse concave-up ST elevation and PR segment depression in most of the leads and reciprocal PR segment elevation and ST depression in aVR. .. Episodes of complete heart block. Note >1 nonconducted P in a row. Note old inferior and acute anterior STEMI and mechanism of heart block is likely to be infra-Hisian with high risk of lack of escape rhythm. .. Premature ventricular contractions (PVCs), three-beat VT (beats 2–4), accelerated idiojunctional rhythm (fairly regular narrow complex with no preceding P at a rate of 65 bpm, beats 9–12), Afib (lack of a P wave), short QT interval. These are highly indicative of digoxin toxicity. Digoxin toxicity blocks AV node and promotes subsidiary pacemakers at a faster rate. .. Junctional rhythm with ventricular bigeminy. .. Junctional rhythm with RBBB (beats 1, 4, and 5) with intermittent V-pacing (beats 2, 3, 6, and 7). Note a small pacer spike, changed QRS morphology upright in I, and different T wave morphology with paced beats. .. Dual-chamber pacing. .. Ventricular bigeminy. .. Atrial pacing, ventricular tracking with ventricular pseudofusion. The V-spike before QRS is coincidental and QRS has normal conducted morphology. Lengthening AV delay will conserve the battery. .. Dual-chamber pacing with ventricular couplet (beats 7 and 8). .. Atrial flutter with 2 : 1 conduction and intermittent V-pacing. .. WPW syndrome. .. Dual-chamber pacer with atrial sensing and V-pacing producing slightly fused complex. Only very initial part of QRS is slightly slurred, indicating pacer-induced depolarization and rest of the QRS is normally conducted. Note LAFB as well. .. High-grade AV block. The P waves are numbered. The atrial rate is about 86 bpm, and between 1 and 2 (rate 43) a P wave is dropped, indicating 2 : 1 sino-atrial block (produced by a nonconducted premature atrial contraction (PAC) between 1 and 2 through concealed retrograde conduction. The PAC is deforming the ST segment). Then there is 2 : 1 A : V block till 7 followed by two successive Ps being dropped (complete AV block) with a ventricular escape beat at 9 burying a P wave. .. Narrow complex regular tachycardia at a rate of 150 .bpm without a discernible P wave. Likely paroxysmal SVT and possible atrioventricular nodal reentry tachycardia. .. Broad complex tachycardia at a rate of 140 bpm, suggestive of VT. Note negative concordance in chest leads, superior axis, QRS duration of >200 ms, and slow upstroke of QRS complex – all suggestive of VT. .. Atrial flutter with 2 : 1 conduction. Note clear flutter waves in lead II. There is a single PVC. 2 Electrocardiography .. Atrial paced rhythm with normal AV conduction and normal QRS. .. Atrial sensed and ventricular paced rhythm. Note that QRS is upright in V1, suggesting probable LV rather than RV pacing. Patient has a biventricular (BiV) pacer. Chapter 2 .. WPW syndrome. Note the delta waves in V4 and V5. .. Dual-chamber pacer with atrial tracking and V-pacing producing fusion QRS complexes with initial portion due to pacing and remainder being conducted. .. VOO pacing with pacer competing with junctional rhythm producing fully paced beat (1), fusion complex (2), pseudofusion (3), and lack of sensing (5–9). Also note QT prolongation. T wave inversion can occur because of repolarization memory secondary to V-pacing. .. Dual-chamber pacing. .. WPW syndrome, probably posteroseptal pathway because of inferior Q waves, positive delta waves in anterolateral leads, and rapid transition from V1 to V2. .. BiV pacer with atrial and LV pacing. Note that QRS is negative in lateral leads and positive in V1, indicating LV pacing. .. Broad complex tachycardia at a rate of 140 bpm with QRS duration of 160 ms, RBBB pattern with right rabbit ear and right axis deviation and rapid upstroke of initial part of QRS (in V5/V6) with broadening of latter part suggesting SVT with aberrancy. Note that the PVC did not reset the rhythm. .. Broad complex tachycardia with monophasic RBBB pattern in V1, right axis deviation, and QRS duration of 160 ms. No P waves seen. Note rapid rise of QRS voltage in V5 and V6. The patient had SVT with aberrancy. .. Atrial fibrillation for the first five beats, then V-pacing for a beat followed by sinus rhythm with first-degree AV block and lack of V-sensing in last three beats. Also note acute anterior STEMI. .. BiV pacer. Patient is paced in atrium and left ventricle, producing RBBB QRS morphology. .. Blocked PACs. The pauses are due to nonconducted PACs which occurred on the T wave and during refractory period of AV node. This does not signify AV nodal disease. When there are pauses, always look for nonconducted PACs. Also note QT prolongation. .. Acute inferolateral STEMI. Note reciprocal ST depression in aVR; in pericarditis, there is reciprocal ST and PR segment elevation in aVR. .. BiV hypertrophy. R in V1 is >5 mm and R/S in V1 is 1, suggesting RVH. R in V5 plus S in V2 is 35 mm, and ST depression in V5 and V6 suggests LV hypertrophy (LVH). .. Normal electrocardiogram. .. Acute inferior STEMI with near-complete ST segment resolution and inferior Q waves. .. Acute inferolateral STEMI. .. Multifocal atrial tachycardia. Note three different P wave morphologies and average rate >100 bpm. Cardiology Board Review .. Sinus tachycardia. .. Intermittent dropped QRSs without progressive PR prologation suggesting second-degree Mobitz type II AV block. Also note that patient has left bundle Chapter 2 branch block (LBBB), further supporting that the mechanism of AV block is likely infra-Hisian rather than intranodal. High risk of complete heart block. .. Bifascicular block. Patient has RBBB and right axis deviation, suggesting left posterior fascicular block. Note the peaks of R wave in leads II and III follow lead I, suggesting activation spreading from lateral to inferior wall, the region of posterior fascicle. .. Dual-chamber pacing, but QRS is native rather than paced. The V-spike comes before QRS, but QRS is narrow and has near-normal morphology. .. Inferior myocardial infarction, age undetermined, possibly recent (slight ST elevation in leads III and aVF. .. Bifascicular block with RBBB and LAFB. Also note absence of r in leads V1 to V4, indicating anterior myocardial infarction. Hence, the likely mechanism is diffuse conduction system disease through ischemia and signifies high risk because of infra-Hisian mechanism and extent of myocardial involvement. .. Severe hyperkalemia with near sine wave appearance: Note peaked T waves, QRS prolongation, and absent P waves. .. Atrial flutter with 2 : 1 conduction. The atrial rate is 240 bpm and ventricular rate is 120 bpm. .. Marked respiratory sinus arrhythmia. Note that the P wave morphology is constant and cyclical changes in P–P intervals are consistent with frequency of respiration. It is a marker of vagotonia and seems to be more marked in the young and at slow heart rates. .. Atrial tachycardia with variable block. .. Paroxysmal atrial fibrillation with rapid ventricular response. .. Atypical atrial flutter with variable block and IVCD of LBBB morphology. .. Atrial tachycardia with 3 : 1 conduction. Atrial rate is about 225 bpm, and this could also be slow flutter because of antiarrhythmic therapy. Box . ECG Diagnostic Criteria Normal sinus P wave r r r P wave duration <120 ms Amplitude ≤2.5 mm P wave axis between 45◦ and 75◦ in frontal plane Criteria for left atrial enlargement r r P wave duration >120 ms in lead II Notched P wave in lead II with inter-notch distance >40 ms (P-mitrale) 2 Electrocardiography r r P-terminale in V1 >0.04 mm P wave axis between +45◦ and −30◦ in frontal plane (left axis deviation) Criteria for right atrial enlargement r r r P wave amplitude >2.5 mm in lead II (P-pulmonale) Area under initial positive part of P wave in V1 >0.06 mm P wave axis >75◦ in frontal plane (right axis deviation) Criteria for LVH r r r Sokolov criteria: S in V1 plus R in V5 or V6 >35 mm; R in aVL >11 mm Cornell criteria: S in V3 plus S in V1 ≥28 mm for men and ≥20 mm for women Romhilt–Estes criteria (LVH if 5 points): R wave in any limb lead ≥20 mm, or S in V1 or V2 ≥30 mm, or R in V5 or V6 ≥30 mm (3 points); left atrial abnormality (3 points); ST–T changes without digoxin (3 points) or with digoxin (1 point); QRS axis <−30◦ (2 points); QRS duration >90 ms (1 point); intrinsicoid deflection in V5 or V6 >50 ms (1 point) Criteria for RVH r r r r r r R in V1 ≥7 mm QR in V1 R/S in V1 >1 with R at least 5 mm R/S in V5 or V6 <1 S1 Q3 T3 pattern (pulmonary embolism) S1 S2 S3 pattern Criteria for BiV hypertrophy r r r r Tall R in both left and right chest leads LVH with right axis deviation LVH with deep S in V5 or V6 LVH with shift of precordial transition (R∕S = 1) to the left of V4 Criteria for LAFB r QRS axis <−45◦ with rS in inferior leads (i.e., no inferior Q waves) and qR in high lateral leads plus QRSd <120 ms Criteria for left posterior fascicular block r QRS axis >120◦ with RS in high lateral leads and qR in inferior leads plus QRSd <120 ms Criteria for LBBB r Broad notched R wave in lateral leads, absent q in left-sided leads (septal activation will be right to left), QRSd ≥120 ms Criteria for RBBB r Broad notched R wave in V1 and V2 with right rabbit ear, deep slurred S in left-sided leads (reciprocal of R′ ), QRSd ≥120 ms Chapter 2 Cardiology Board Review Causes of tall R wave in V r Chapter 2 r r r r r r RVH (generally with right axis deviation and secondary ST–T changes or right atrial enlargement) True posterior infarct (generally with upright T, inferior or lateral Q) Hypertrophic obstructive cardiomyopathy (due to septal depolarization) Duchenne muscular dystrophy RBBB WPW syndrome with posterior or lateral pathways Heart shifted to right Causes of Q waves r r r r r r r Normal in V1/V2 and III (in lead III will disappear with deep breath which makes heart vertical) Myocardial infarction Myocardial infiltration (sarcoid, amyloid) Myocarditis WPW syndrome LBBB results in Q in V1/V2 Hypertrophic obstructive cardiomyopathy (septal hypertrophy causing Q in lateral leads) Causes of ST elevation r r r r r r r r Normal variant (early repolarization, generally V1–V4) Myocardial injury (convex up) LV aneurysm (persistent beyond 6 months) Pericarditis (concave up, diffuse, ST and PR elevation in aVR, PR depression) Brugada syndrome Hyperkalemia (“dialyzable current of injury”) Type IC antiarrhythmic agents LVH and LBBB (in right chest leads as reciprocal of ST depression on left chest leads) Hyperkalemia r r r r Peaked T wave (early sign) Increased QRS duration Absent P wave Sine wave morphology in late stage Hypercalcemia r Shortened QT interval Hypocalcemia r QT lengthening (especially ST segment lengthening) Chest X-Ray in Cardiology .. A 52-year-old African American male was admitted with complaints of shortness of breath and edema. He has a history of methamphetamine use. A chest X-ray (Figure 3.1a) was performed in the emergency room (ER). What does the chest X-ray show? A. Cardiomegaly B. Cardiomegaly, automatic implantable cardioverter-defibrillator (AICD) lead C. Normal findings D. Cardiomegaly, AICD lead, left pleural effusion Figure .a .. An 84-year-old male was admitted with shortness of breath. He was diagnosed with left pleural effusion. He underwent thoracentesis. A few hours later he developed increasing oxygen requirements. A chest X-ray was done (see Figure 3.2a). What does it show? A. Pulmonary edema B. Right apical pneumothorax C. Left apical pneumothorax D. Right-sided pneumonia Cardiology Board Review, First Edition. Ramdas G. Pai, Padmini Varadarajan and Sudha M. Pai. © 2018 John Wiley & Sons, Ltd. Published 2018 by John Wiley & Sons, Ltd. Cardiology Board Review Chapter 3 Figure .a .. A 59-year-old male was admitted with a history of subarachnoid hemorrhage. A PA chest X-ray (Figure 3.3a) was performed in the ER. What does the chest X-ray show? A. Normal chest X-ray B. Prosthetic valve in the mitral position Figure .a 3 Chest X-Ray in Cardiology C. Prosthetic valve in the aortic position D. Prosthetic valves in the aortic and mitral positions .. A 75-year-old male presented to the ER with complaints of shortness of breath. A chest X-ray (Figure 3.4a) was performed in the ER. What does the X-ray show? A. Left pleural effusion Chapter 3 B. Right pleural effusion C. Consolidation D. Pulmonary edema Figure .a .. A 59-year-old Pakistani male presented to the ER with complaints of headache. He had a computed tomography (CT) scan of his head, which showed evidence of subdural hemorrhage. He also had a chest X-ray (Figure 3.5a) in the ER. What does the X-ray show? A. Bioprosthetic valve in the aortic position B. Bileaflet mechanical prosthesis in the mitral position C. Bioprosthetic valve in the mitral position D. No prosthetic valve is seen .. A 56-year-old male presented to the ER with complaints of shortness of breath on exertion, cough with whitish expectoration, and pedal edema. In the ER he had a chest X-ray (see Figure 3.6a). What is the most important finding on the X-ray? A. Pneumothorax B. Right pleural effusion only C. Left pleural effusion D. Bilateral pleural effusion E. No abnormality seen Cardiology Board Review Chapter 3 Figure .a Figure .a 3 Chest X-Ray in Cardiology .. A 39-year-old male presented to the hospital after a cardiac arrest at home. He was brought to the hospital and had a chest X-ray (Figure 3.7). What does the chest Xray show? A. Normal heart size C. Left pneumothorax B. Cardiomegaly D. Right pneumothorax Figure . .. A 51-year-old male came to the hospital with complaints of fatigue, cough. He had a chest X-ray (see Figure 3.8a) in the ER. What does his chest X-ray show? A. Normal aortic size B. Prominent aortic knob C. Prominent main pulmonary artery D. Prominent left bronchus .. The patient in Question 3.8 then had an echocardiogram. He had mild tricuspid regurgitation, velocity of 4.7 m/s, elevated right atrial pressure of 20 mmHg, and estimated pulmonary artery systolic pressure of 110 mmHg. What are these findings suggestive of? A. Primary pulmonary hypertension B. Pulmonary vascular congestion C. Right to left shunt D. None of the above .. A 69-year-old male was admitted to the hospital complaining of shortness of breath. His initial chest X-ray showed pulmonary edema and he was started on intravenous diuretics. Two days later he complained of feeling feverish, Chapter 3 Cardiology Board Review Chapter 3 Figure .a temperature was 101◦ F, with chills and greenish expectoration. What does the repeat chest X-ray (Figure 3.10a) show? A. Pulmonary edema B. Right hilar consolidation with superimposed pulmonary vascular congestion C. Left hilar consolidation D. Right hilar consolidation .. A 62-year-old male was admitted with complaints of shortness of breath. What does the chest X-ray in Figure 3.11a show? A. Left atrial enlargement B. Right ventricular enlargement C. Left ventricular enlargement D. Right atrial and right ventricular enlargement .. An 80-year-old female patient has a history of long-standing systolic murmur at the base. She had a chest X-ray (Figure 3.12a). What is the most important finding? A. Marked enlargement of main pulmonary artery B. Marked enlargement of the aorta C. Marked enlargement of the right pulmonary artery D. Marked enlargement of the main pulmonary artery and left pulmonary artery .. What does the blue arrow point to on the chest X-ray in Figure 3.13? A. Enlarged left atrium C. Enlarged pulmonary artery B. Aortic knob D. None of the above 3 Chest X-Ray in Cardiology Chapter 3 Figure .a Figure .a Cardiology Board Review Chapter 3 Figure .a Figure . 3 Chest X-Ray in Cardiology .. What structure indicated by the blue arrow in Figure 3.14 forms the cardiac boundary: A. Ascending aorta C. Right pulmonary artery B. Arch of the aorta D. Superior vena cava Chapter 3 Figure . .. Figure 3.15a shows a 93-year-old female patient with a history of shortness of breath who has undergone what procedure? Figure .a Cardiology Board Review A. Surgical replacement of mitral valve B. Surgical replacement of aortic valve C. Transaortic valve replacement (TAVR) D. None of the above Chapter 3 .. The patient in Question 3.15 has also undergone another procedure. What is this other procedure? A. Permanent single-chamber pacemaker B. Dual-chamber pacemaker C. Dual-chamber AICD D. None of the above .. What does the blue arrow in Figure 3.17 point to? A. Right atrial pacer lead B. Right ventricular pacer lead C. Right ventricular implantable cardioverter-defibrillator (ICD) lead D. Coronary sinus lead Figure . .. What does the blue arrow in Figure 3.18 point to? A. Right atrial pacer lead C. Right atrial ICD lead B. Right ventricular ICD lead D. Coronary sinus lead .. What does the blue arrow in Figure 3.19a point to? A. Right atrial pacer lead B. Right ventricular ICD lead C. Right atrial ICD lead D. Coronary sinus lead 3 Chest X-Ray in Cardiology Chapter 3 Figure . Figure .a Chapter 3 Cardiology Board Review .. What does the blue arrow in Figure 3.20 point to? A. A pacer lead B. Catheter placed through left subclavian vein C. Arterial line D. None of the above Figure . .. What does the blue arrow in Figure 3.21 point to? A. Catheter placed through right internal jugular vein B. Catheter through right subclavian vein C. Pacer lead D. None of the above .. An 86-year-old male with history of chronic obstructive pulmonary disease is admitted to the hospital. After a day he was noted to be hypoxic. He also complained of feeling feverish and increasingly short of breath. Referring to Figure 3.22a, what procedure did he undergo? A. Placement of central line C. Endotracheal intubation B. Placement of a pacer D. Thoracentesis .. The arrow in Figure 3.23 points to which landmark on the chest X-ray from the patient in Question 3.22? A. Carina C. Esophagus B. Main pulmonary artery D. Aorta .. The arrow in Figure 3.24 points to what structure on the chest X-ray? A. Nasogastric tube B. Percutaneous endoscopic gastrostomy tube C. Central venous catheter D. None of the above 3 Chest X-Ray in Cardiology Chapter 3 Figure . Figure .a Cardiology Board Review Chapter 3 Figure . Figure . 3 Chest X-Ray in Cardiology .. A 59-year-old Hispanic female patient was admitted to the hospital with complaints of fever and shortness of breath. A chest X-ray was performed (see Figure 3.25a) and she had which of the following procedures performed? A. Pericardiocentesis B. Placement of a catheter in the right pleural space Chapter 3 C. Placement of a catheter in the left pleural space D. Right paracentesis Figure .a .. The chest X-ray in Figure 3.26a shows which of the following: A. Dextroposition B. Dextrocardia C. Levocardia D. Mesocardia .. A 69-year-old male with a history of heart transplant 10 years ago is complaining of low-grade fever, fatigue, and loss of appetite. He had a chest X-ray (see Figure 3.27a) as part of his work up. What does this chest X-ray show? A. Normal chest X-ray B. A rounded opacity in the right lower lobe C. Patchy consolidation in the left lower lobe D. Multiple lung nodules .. Plethoric lung fields on chest X-ray are seen in all of the following except: A. ASD B. Ventricular septal defect (VSD) C. Patient ductus arteriosus (PDA) D. Mitral stenosis Cardiology Board Review Chapter 3 Figure .a Figure .a 3 Chest X-Ray in Cardiology .. What is peripheral pulmonary artery pruning a feature of? A. Pulmonary hypertension B. Pulmonary stenosis C. Acute pulmonary embolism D. Pulmonary regurgitation .. Dilated main pulmonary artery (jug handle appearance) in a patient with Eisenmenger’s syndrome is indicative of: A. ASD Eisenmenger’s B. VSD Eisenmenger’s C. PDA Eisenmenger’s .. Straightened left heart border is classically seen in which of the following: A. Mitral stenosis B. Aortic stenosis C. ASD D. PDA .. Coeur en Sabot is a feature of which of the following: A. Tetralogy of Fallot B. Aortic coarctation C. Dilated cardiomyopathy D. Hypertrophic cardiomyopathy .. Snowman appearance is a classic description of which of the following: A. Partial anomalous pulmonary venous drainage B. Total anomalous pulmonary venous drainage C. Ebstein’s anomaly D. ASD .. Scimitar sign is seen in which of the following: A. Partial anomalous pulmonary venous drainage B. Total anomalous pulmonary venous drainage C. Ebstein’s anomaly D. ASD .. An increase in subcarinal angle due to lifting of left bronchus is a feature of which of the following: A. Left ventricular hypertrophy B. Left atrial dilation C. Right atrial dilation D. Pulmonary ectasia Answers .. D. Cardiomegaly, AICD lead, left pleural effusion. The cardiomediastinal ratio is increased, which is indicative of cardiomegaly (red arrow in Figure 3.1b). There is also an AICD lead in the right ventricle (blue arrow in Figure 3.1b). The left costophrenic angle is blunted, which is suggestive of presence of pleural effusion. Chapter 3 Cardiology Board Review Chapter 3 Figure .b .. C. Left apical pneumothorax. The patient had thoracentesis, which then caused left apical pneumothorax: blue arrow in lateral view (Figure 3.2b); multiple arrows in posteroanterior (PA) view (Figure 3.2c). The pneumothorax was drained with a chest tube. Figure .b 3 Chest X-Ray in Cardiology Chapter 3 Figure .c .. D. Prosthetic valves in the aortic and mitral positions The chest X-rays (Figures 3.3b and 3.3c) show two mechanical valve prosthetic rings: one in the aortic (red arrow) and another in the mitral position (blue arrow). Mitral is to the left of the midline, caudal and posterior. Figure .b Cardiology Board Review Chapter 3 Figure .c .. B. Right pleural effusion. The right costophrenic angle is blunted. The lower to middle lung zones are indistinct and markings are obscured. The chest X-ray shows the presence of right pleural effusion, shown by the blue arrow in Figure 3.4b. Figure .b 3 Chest X-Ray in Cardiology .. B. Bileaflet mechanical prosthesis in the mitral position. The chest X-ray shows sternal wires indicative of previous surgery (red arrow in Figure 3.5b). There is a bileaflet mechanical prosthesis in the mitral position (blue arrow in Figure 3.5b). The patient’s international normalized ratio was 13 and probably caused the subdural hemorrhage. Mitral valve LV Figure .b .. D. Bilateral pleural effusion. The chest X-ray shows blunting of both costophrenic angles, which is indicative of bilateral pleural effusion (blue arrows in Figure 3.6b). .. B. Cardiomegaly. The patient’s chest X-ray shows increased cardiomediastinal ratio, which is suggestive of cardiomegaly. .. C. Prominent main pulmonary artery. The main pulmonary artery is enlarged and is prominent (blue arrow in Figure 3.8b). The red arrow points to the left pulmonary artery, which has a pruned appearance in the peripheral lung zones. .. A. Primary pulmonary hypertension. The patient is young, and has a prominent main pulmonary artery on the chest X-ray. His echocardiogram reveals pulmonary hypertension. The lungs fields are not plethoric. Given the findings on chest X-ray and echocardiogram, he has primary pulmonary hypertension. Chapter 3 Cardiology Board Review Chapter 3 Figure .b Figure .b .. B. Right hilar consolidation with superimposed pulmonary vascular congestion. The chest X-ray shows increased pulmonary vascular congestion. But the more striking finding is the presence of right hilar consolidation (blue arrow in Figure 3.10b) suggestive of pneumonia. The less likely differential diagnosis is unilateral right pulmonary edema. 3 Chest X-Ray in Cardiology Chapter 3 Figure .b .. D. Right atrial and right ventricular enlargement. This patient’s chest X-ray shows enlargement of both right atrium (blue arrow in Figure 3.11b) and right ventricle, as evidenced by lifted apex (red arrow). Enlargement of the right ventricle usually causes the apex to be rounded and uplifted, Figure .b Cardiology Board Review as shown by the red arrow. This patient had an echocardiogram which showed enlargement of the right-sided chambers without any signs of a shunt. He then underwent a transesophageal echocardiogram, which revealed a sinus venosus atrial septal defect (ASD). Chapter 3 .. D. Marked enlargement of the main and left pulmonary artery. In Figure 3.12b, the red arrow points to the enlarged main pulmonary artery and the blue arrow points to the enlarged left pulmonary artery. This is suggestive of pulmonary valve stenosis. Figure .b .. B. Aortic knob. .. D. Superior vena cava. .. C. Transaortic valve replacement. This patient with complaints of shortness of breath had severe aortic stenosis. She then underwent a transaortic valve replacement. The bioprosthetic valve is shown by the blue arrow in Figure 3.15b. This is an Edwards valve and has a titanium mesh to hold the leaflets and not just the sewing ring. Also note that there are no sternotomy wires. .. B. Dual-chamber pacemaker. .. B. Right ventricular pacer lead. .. A. Right atrial pacer lead. This patient has a dual-chamber pacemaker with leads in the right atrium and right ventricle. 3 Chest X-Ray in Cardiology Chapter 3 Figure .b .. D. Coronary sinus lead. In this patient’s chest X-ray three leads are visible. In Figure 3.19b, the blue arrow points to the coronary sinus lead. The lead in the right ventricle is thicker than a regular pacing lead and is indicative of an ICD lead (red arrow). The third lead is the right atrial lead (yellow arrow). Figure .b Cardiology Board Review .. B. Catheter placed through left subclavian vein. There is a catheter that has been placed through a left subclavian approach and is terminating at the lower level of the superior vena cava. .. A. Catheter placed through right internal jugular vein. Chapter 3 .. C. Endotracheal intubation. The patient was tachypneic and hypoxic. He had emergent endotracheal intubation and was started on mechanical ventilation. The blue arrow in Figure 3.22b points to the endotracheal tube. Figure .b .. A. Carina. The endotracheal tube can be seen terminating about 1 cm above the carina. .. A. Nasogastric tube. The arrow points to the nasogastric tube, which is terminating below the diaphragm. .. B. Placement of a catheter in the right pleural space. The arrow in Figure 3.25b points to the catheter in the right pleural space. The right costophrenic angle is still obscured. She probably had right pleural effusion that was drained by placement of a right pleural catheter. 3 Chest X-Ray in Cardiology Chapter 3 Figure .b .. B. Dextrocardia. This is a portable chest X-ray. The most striking feature is that the apex of the heart is pointing to the right. This is called dextrocardia. In dextroposition, the apex still points to the left but the heart itself is shifted to the right. The arrow in Figure 3.26b points to the apex of the heart, which is pointing to the right. Figure .b Cardiology Board Review .. B. A rounded opacity in the right lower lobe. The rounded opacity in the right lower lobe is shown by the arrow in Figure 3.27b. Since this patient is status post heart transplant, he is prone to opportunistic infections such as aspergillosis, norcardiosis, and coccidiomycosis. He underwent a CT scan of the lung which again demonstrated the rounded opacity in the Chapter 3 right lower lobe. He underwent CT-guided biopsy and pathology was positive for Norcardia. Also note the elevated left hemidiaphragm, which may suggest left phrenic nerve palsy. Figure .b .. D. Mitral stenosis. Plethoric lung fields are indicative of increased pulmonary blood flow and are seen in left-to-right shunts such as ASD, VSD, and PDA. The pulmonary artery branches are prominently seen up to peripheral lung fields and flow is significantly increased. .. A. Pulmonary hypertension. Peripheral vasoconstriction, along with dilated central pulmonary arteries, results in this appearance in pulmonary hypertension. In pulmonary stenosis, lung fields are oligemic. .. A. ASD Eisenmenger’s. Severely dilated main pulmonary artery is a feature of large ASD. In large VSDs, as pulmonary artery pressure does not regress during childhood, pulmonary artery tends to have thicker walls and hence does not dilate as much. .. A. Mitral stenosis. Filling of the bay between main pulmonary artery and left ventricle by the dilated left atrial appendage in mitral stenosis causes straightening of left heart border. 3 Chest X-Ray in Cardiology .. A. Tetralogy of Fallot. This is due to right ventricular hypertrophy, which lifts the apex up mimicking the wooden boots of Danish farmers. .. B. Total anomalous pulmonary venous drainage. .. A. Partial anomalous pulmonary venous drainage. Chapter 3 Partial anomalous pulmonary venous drainage from right upper pulmonary vein to inferior vena cava results in a scimitar-shaped shadow along right heart border. Diagnosis is confirmed by transesophageal echocardiography. .. B. Left atrial dilation. This is typically seen in mitral stenosis due to severe left atrial enlargement. Dilated left atrium may also show as a double atrial shadow near right atrial border with acute angulation with right hemidiaphragm, pressure on left recurrent laryngeal nerve causing hoarseness of voice (Ortner’s syndrome), and dysphagia due to pressure on esophagus. Pressure on esophagus is best appreciated by performing a barium swallow. Stress Testing and Risk Stratiﬁcation of Asymptomatic Subjects .. A 45-year-old male comes to your office for evaluation of chest pain. He reports substernal chest pressure, lasts a few minutes, does not radiate to his shoulder or jaw, occurs with exertion sometimes, and is relieved on its own in a few minutes. His risk factors include hypertension controlled on hydrachlorothiazide and amlodipine. He also was a 20 pack a year smoker, but quit a month ago. His electrocardiogram (ECG) shows no abnormalities. To evaluate his chest pain, what should the next step be? A. Coronary angiography B. Exercise stress echocardiogram C. Exercise stress test D. No testing needed at this time .. The patient walked for 5 min on the treadmill (Bruce protocol) and had to stop the test due to substernal chest pressure. His peak stress blood pressure (BP) dropped to 90 mmHg from a resting pressure of 130 mmHg. His stress ECG shows 4 mm downsloping ST depressions in the anterior chest leads that last 5 min into recovery. He is nauseous and diaphoretic. What is the next step in his evaluation? A. Nothing at present B. Adenosine myocardial perfusion imaging (MPI) C. Coronary angiogram to evaluate for obstructive CAD D. Modify medical therapy .. A 55-year-old male comes to your office for evaluation of chest pain. He reports no cardiac risk factors other than hypercholesterolemia. He describes his chest pain as a discomfort, in the central chest, occurs at rest, lasts a few minutes, and is relieved with aspirin. A resting ECG done in the office reveals preexcitation. What does the next step in his evaluation include? A. Exercise stress test B. Coronary angiogram C. Referral to an electrophysiologist D. Exercise myocardial perfusion .. In the evaluation of a patient with chest pain and right bundle branch (RBBB) on ECG, which of the following is true regarding exercise stress testing? A. Stress test is not useful in patients with RBBB B. Stress testing should always be combined with imaging C. Stress testing can be undertaken without affecting the predictive value of stress ECG D. None of the above Cardiology Board Review, First Edition. Ramdas G. Pai, Padmini Varadarajan and Sudha M. Pai. © 2018 John Wiley & Sons, Ltd. Published 2018 by John Wiley & Sons, Ltd. 4 Stress Testing and Risk Stratification of Asymptomatic Subjects .. A 50-year-old women presents to the emergency room (ER) with complaints of chest pain. Her chest pain started 3 days prior to presentation and radiates to her jaw, occurs with exertion, and is relieved with rest. Her risk factors include hypertension and hypercholesterolemia. Her ECG at presentation is normal. Three sets of cardiac biomarkers drawn at presentation and then 8 h apart are negative. What is the best next recommended step? A. She is at low risk for ischemia; hence, discharge her home with advice regarding Chapter 4 risk factor modification B. Refer her for coronary angiography C. Order a pharmacological stress nuclear study D. Order an exercise stress test .. Which of the following is not a contraindication to exercise ECG stress testing? A. 75-year-old male with complaints of chest pain and one episode of frank syncope. On examination, he has slow rising carotid pulse and a harsh 3/6 ejection systolic murmur with radiation to both carotids. B. A 35-year-old female with complaints of shortness of breath. On examination, jugular venous pressure is elevated, 15 cmH2 O, S3 gallop, and 2+ pedal edema. She has recently delivered her second baby. C. A 68-year-old male with complaints of chest pain. He describes it as a sharp substernal chest pain, worse on deep inspiration. He gives a history of hip replacement 2 weeks ago. D. A 44-year-old male with complaints of chest pain brought on by exertion, started a month ago. Physical examination is unremarkable except for an elevated BP of 140/78 mmHg. His ECG shows first-degree atrioventricular block and incomplete RBBB. E. A 65-year-old male presents to the ER with exertional chest pain. Pain started 24 h prior to presentation. He is currently chest-pain free. His ECG showed sinus bradycardia with Q waves in anterior chest leads V1–V4. An ECG done 1 month ago at his doctor’s office was completely normal. .. Which is an indication to stop an exercise treadmill test? A. Drop of >10 mmHg from baseline BP despite an increase in workload with associated features of ischemia B. Sustained ventricular tachycardia C. Moderate to severe angina D. Signs of cyanosis or pallor E. All of the above .. Which of the following is a class III indication for exercise stress testing without imaging (echo or nuclear perfusion)? A. Patients with a high pretest probability of having CAD B. Preexcitation on baseline ECG C. Left ventricular hypertrophy with <1 mm ST depression on baseline ECG D. Patient with vasospastic angina .. A 45-year-old male is being evaluated by his primary care physician as part of his executive health checkup. He reports no risk factors and is asymptomatic. His baseline ECG shows no resting abnormalities. He is able to walk for 14 min (13.5 METS on a Bruce protocol). He reaches an exercise heart rate of 185 bpm, has Cardiology Board Review no angina, and has no ST segment changes on his ECG. What would his Duke treadmill score be? A. 9 B. 14 C. 2 D. 3.4 Chapter 4 .. Based on the test results in Question 4.9, what is the next most appropriate step? A. Stress imaging study B. Computed tomography (CT) angiography C. Coronary angiography D. No further testing E. Repeat testing in 1 year .. Which one of the following is a class I recommendation in assessing asymptomatic adults with no known CAD? A. Genomic testing B. Obtain global risk score (Framingham) C. Assessment of lipoprotein and apolipoprotein D. Measurements of natriuretic peptides .. Which one of the following is a class I recommendation in assessing asymptomatic adults with no known CAD? A. Genomic testing B. Obtain family history C. Assessment of lipoprotein and apolipoprotein D. Coronary CT angiogram .. Measurement of C-reactive protein (CRP) is not recommended in which of the following? A. In men over 50 years with a low-density lipoprotein (LDL) of <130 mg/dL B. In women over 60 years with an LDL <130 mg/dL not on hormone replacement therapy, and without diabetes or chronic kidney disease C. In asymptomatic high-risk adults D. In asymptomatic intermediate-risk men 50 years and younger or women 60 years and younger .. With one exception, the following are class III recommendations in assessing lowrisk asymptomatic adults with no known history of CAD. Which is the exception? A. Coronary CT angiogram B. Magnetic resonance imaging (MRI) for plaque detection C. Measurement of coronary calcium score D. Resting ECG .. In patients with diabetes mellitus, which of the following is not recommended? A. Stress echocardiogram B. Stress MPI C. Coronary calcium score measurement D. Measurement of hemoglobin A1C .. In asymptomatic women, all of the following except one are not recommended. Which is the exception? 4 Stress Testing and Risk Stratification of Asymptomatic Subjects .. .. .. .. .. A. Obtaining global risk score B. Obtaining natriuretic peptides C. MRI for plaque detection D. Measurement of lipoprotein Stress MPI is recommended in which of the following situations? A. In the assessment of a low-risk individual B. In the assessment of an intermediate-risk individual Chapter 4 C. In an asymptomatic adult with diabetes mellitus D. None of the above Which of the following is not true? A. Echocardiography is recommended to detect left ventricular hypertrophy in patients with hypertension B. Echocardiography is recommended in risk assessment of asymptomatic adults without hypertension C. A resting ECG is reasonable in asymptomatic adults with hypertension D. All of the above Which of the following is a class III indication in the assessment of asymptomatic adults? A. Measurement of arterial stiffness B. Obtaining a resting ECG C. Obtaining an echocardiogram in a patient with hypertension D. Stress MPI in an individual with diabetes mellitus Which of the following is not indicated regarding assessment of an asymptomatic adult with diabetes mellitus A. Measurement of hemoglobin A1C B. Stress MPI C. Testing for microalbuminuria D. Coronary CT angiogram The thallium scan in Figure 4.21 (study 2 is a 4 h redistribution) is from a 47year-old man presenting with chest pain and ejection fraction (EF) of 35%. The coronary angiogram showed origin occlusion of LAD with collaterals from the right. Rest of the vessels were normal. What would you do? A. Refer for single-vessel coronary artery bypass grafting with possible left internal mammary artery to left anterior descending (LAD) artery B. Perform a positron emission tomography scan for viability C. Refer for implantable cardioverter-defibrillator D. None of the above .. A 55-year-old man with diabetes and prior myocardial infarction with a right coronary artery (RCA) stent presented with chest pain. His cardiac markers were normal and EF on echo was 45% with inferior wall hypokinesis. The results of a stress Sestamibi scan are shown in Figure 4.22. What would you recommend? A. Coronary angiography B. Do stress echo C. Perform stress perfusion scan in 6 months D. Medical management only at this point Cardiology Board Review Chapter 4 Figure . Figure . 4 Stress Testing and Risk Stratification of Asymptomatic Subjects .. A 67-year-old man with hypertension and diabetes presented with central chest pain lasting 30 min. There were no ECG changes, and cardiac markers were negative. The results of a stress perfusion study are shown in Figure 4.23. What will you recommend? A. Coronary angiography B. Medical management only C. Perform stress echo Chapter 4 D. None of the above Figure . .. What is the stress perfusion image shown in Figure 4.24 suggestive of? A. Reversible ischemia of large LAD area B. Infarct of LAD area C. Ischemia of RCA area D. Ischemia of circumflex area .. What does the stress perfusion image in Figure 4.25 show? A. Reversible apical perfusion defect B. Reversible defect of entire LAD area C. Inferior wall ischemia D. Apical infarct .. What is the stress perfusion scan in Figure 4.26 suggestive of? A. Perfusion defect in LAD area B. Ischemia of inferior wall C. Apical infarct D. Normal rest and stress perfusion .. The results of stress perfusion only are shown in Figure 4.27 (no rest perfusion shown). What are the results indicative of? A. Normal stress perfusion and normal left ventricular wall motion B. Normal perfusion with inferior hypokinesis C. Anterior perfusion defect with normal wall motion D. Inferior perfusion defect with inferior hypokinesis Cardiology Board Review Chapter 4 Figure . Figure . 4 Stress Testing and Risk Stratification of Asymptomatic Subjects Chapter 4 Figure . Figure . Cardiology Board Review .. What is the rest/stress perfusion study shown in Figure 4.28 indicative of? A. Inferior wall infarction B. Inferior wall ischemia C. Inferior and anterior ischemia D. Anterior wall infarct with minor reversibility Chapter 4 Figure . .. What is the patient whose rest/stress perfusion test results are shown in Figure 4.29 likely to have? A. Severe LAD artery lesion B. Left main lesion C. Circumflex lesion D. RCA lesion .. A 66-year-old diabetic presented to the ER with chest pain. The resting ECG showed nonspecific ST–T changes, and cardiac markers were negative. The patient was on metformin, aspirin, atorvastatin, and lisinopril, with heart rate of 68 bpm and BP of 123/78 mmHg. Cardiac examination was normal. The patient’s nuclear stress test is shown in Figure 4.30. What will be a next logical step? A. Admit for further observation B. Refer for coronary angiography C. Discharge home and continue medical management D. Perform an echocardiogram 4 Stress Testing and Risk Stratification of Asymptomatic Subjects Chapter 4 Figure . Figure . Cardiology Board Review .. The vasodilator stress study shown in Figure 4.31 is indicative of what? A. Normal perfusion B. Ischemia in LAD area C. Ischemia in RCA area D. Ischemia in circumflex area Chapter 4 Figure . Answers .. C. Exercise stress test. This patient has atypical chest pain. He has risk factors that warrant further testing. His ECG shows no resting abnormalities. If the patient is able to exercise, first step in his evaluation should be exercise stress testing. According to the American College of Cardiology (ACC)/American Heart Association (AHA) 2002 guidelines (Gibbons et al., 2002), if a patient has stable chest pain, has- low to intermediaterisk unstable angina, has symptoms that warrant a diagnosis of coronary artery disease (CAD), is able to exercise, and has an interpretable ECG, then exercise stress testing is the first step. .. C. Coronary angiogram to evaluate for obstructive CAD. This patient has several high-risk features on his stress test. He walked only 5 min on a Bruce protocol, having to stop due to chest pain. He had significant ST depression at low level of stress that was accompanied by a drop in his systolic BP. These features point to significant CAD. He should be referred for a coronary angiogram. 4 Stress Testing and Risk Stratification of Asymptomatic Subjects .. D. Exercise myocardial perfusion. This patient’s resting ECG shows preexcitation. According to the ACC/AHA guidelines (Gibbons et al., 2002), class III indications for exercise stress test alone without imaging include preexcitation (Wolff–Parkinson–White) syndrome, electronically paced ventricular rhythm, greater than 1 mm resting ST depression, and complete left bundle branch block. .. C. Stress testing can be undertaken without affecting the predictive value of stress Chapter 4 ECG. With exercise, ST depression usually occurs with RBBB in leads V1–V3. But in leads V4–V6 or the inferior leads, ST changes with stress are similar to those of a normal resting ECG (without RBBB). Hence, the presence of RBBB on resting ECG does not reduce the sensitivity, specificity, or predictive value of the stress ECG in the diagnosis of ischemia. .. D. Order an exercise stress test. This patient has intermediate probability for CAD based on age, gender, and symptoms. Women have a lower prevalence of obstructive CAD; exercise stress test, which is used to detect focal stenosis, is less sensitive and specific in women. Women tend to have resting ST and T wave changes which can get more pronounced with stress, causing decreased accuracy when used to detect focal disease. Despite the lower accuracy of exercise stress ECG testing, the 2005 ACC/AHA guidelines on the Role of Noninvasive Testing in the Clinical Evaluation of Women Suspected with Coronary Artery Disease recommends exercise ECG as the first test of choice in women with intermediate risk and normal baseline ECG. In women, other parameters, such as poor exercise capacity, low heart rate recovery, and failure to reach target heart rate, are more predictive of outcome than ST changes with stress. .. D. A 44-year-old male with complaints of chest pain brought on by exertion, started a month ago. Physical examination is unremarkable except for an elevated BP of 140/78 mmHg. His ECG shows first-degree atrioventricular block and incomplete RBBB. The patient in D can safely undergo stress testing. Contraindications to exercise stress ECG testing include severe symptomatic aortic stenosis (scenario A), decompensated heart failure (scenario B), acute pulmonary embolism (scenario C), and within 2 days of an acute myocardial infarction (scenario E). .. E. All of the above. The scenarios listed are all absolute indications to stop the treadmill test. In addition, ST elevation >1 mm in leads without Q waves, the patient’s desire to stop, and technical difficulties in monitoring ECG or BP are all absolute indications to stop the exercise treadmill test. .. B. Preexcitation on the baseline ECG. It is a class III indication to use an exercise stress test in patients with preexcitation, paced ventricular rhythm, greater than 1 mm resting ST depression, and complete left bundle branch block. It is a class IIa indication to perform an exercise stress test in patients with vasospastic angina and class IIb to perform treadmill stress test in patients with high pretest probability for CAD according to ACC/AHA guidelines (Gibbons et al., 2002). Cardiology Board Review .. B. 14. Duke treadmill score is calculated as Exercise time (min) − (5 × Amount of ST deviation (mm)) −(4 × Exercise angina index) (0: none; 1: if exercise angina occurred; 2: if angina was the reason to stop the test). Here, it would be 14 − (5 × 0) − (4 × 0) = 14. Exercise time is based on a standard Chapter 4 Bruce protocol. .. D. No further testing. A Duke treadmill score of >5.5 is suggestive of low risk of death (<1% per year) and hence no further testing is needed. Patients with intermediate score (−10 to +4) have a mortality risk of 1–3% per year and in those with a high risk score (<−10) have a mortality risk of >3% per year. .. B. Obtain global risk score (Framingham). Obtaining a global risk score in asymptomatic adults without a clinical history of CAD is a class I indication. These scores are helpful in combining individual risk factor measurements into a single quantitative estimate of risk that can be use in prevention strategies. It is not recommended to perform genomic testing or measure lipoprotein or natriuretic peptides in this population; these are considered to be a class III indication (Greenland et al., 2010). .. B. Obtain family history. Obtaining a family history of atherothrombotic coronary vascular disease is recommended in the assessment of asymptomatic adults (Greenland et al., 2010). .. C. In asymptomatic high-risk adults. Measurement of CRP is not recommended in asymptomatic high-risk adults (class III). In men 50 years and older or women 60 years and older with an LDL of <130 mg/dL and not on lipid-lowering therapy, hormone replacement therapy, or immunosuppressive therapy, without clinical CAD, diabetes mellitus, chronic kidney disease, severe inflammatory conditions, or contraindications to statin therapy, CRP can be used to select patients for statin therapy (class IIa). It is also deemed reasonable to measure CRP in asymptomatic intermediate-risk men younger than 50 or women younger than 60, for assessment of CAD risk (class IIb) (Greenland et al., 2010). .. D. Resting ECG. A resting ECG may be reasonable in the assessment of asymptomatic adults with no history of hypertension or diabetes mellitus (class IIb). It is a class III indication to obtain coronary CT angiogram, coronary calcium score, or MRI for plaque detection in low-risk asymptomatic individuals (Greenland et al., 2010). .. A. Stress echocardiogram. In asymptomatic adults with diabetes mellitus it is reasonable to measure coronary calcium score (class IIa). It is also reasonable to measure hemoglobin A1C and stress MPI (class IIb). Stress MPI may be considered for patients with diabetes or when prior risk assessment suggests high risk, such coronary artery calcium of over 400 (Greenland et al., 2010). .. A. Obtaining global risk score. It is a class I indication to obtain a global risk score in all asymptomatic women. 4 Stress Testing and Risk Stratification of Asymptomatic Subjects .. C. In an asymptomatic adult with diabetes mellitus. Stress MPI may be considered for advanced cardiovascular risk assessment in asymptomatic individuals with diabetes mellitus or in adults with a strong family history of CAD, or when prior risk assessment such as a coronary artery calcium score of over 400. Stress MPI is not recommended for assessment of low- or intermediate-risk asymptomatic individuals (class III) (Greenland et al., 2010). Chapter 4 .. B. Echocardiography is recommended in risk assessment of asymptomatic adults without hypertension. It is a class III indication to perform echocardiography in asymptomatic adults without hypertension. A resting ECG can be obtained in patients with hypertension or diabetes (class IIa) or an echocardiogram obtained in patients with hypertension to detect left ventricular hypertrophy (class IIb) (Greenland et al., 2010). .. A. Measurement of arterial stiffness. Measurement of arterial stiffness is a class III indication at the present time (Greenland et al., 2010). .. D. Coronary CT angiogram. It is a class III indication to obtain a coronary CT angiogram in an asymptomatic adult with diabetes (Greenland et al., 2010). .. A. Refer for single-vessel coronary artery bypass grafting with possible left internal mammary artery to left anterior descending (LAD) artery. Though there is no redistribution, the resting scan shows significant thallium uptake in the anterior wall and septum, indicating viability and revascularization is appropriate. There is good probability that EF will improve, obviating the need for a primary prevention implantable cardioverter-defibrillator. .. D. Medical management only at this point. There is only a fixed inferior wall defect attributable to an old myocardial infarction. There are no reversible defects. .. A. Coronary angiography. Note the fully reversible perfusion defect in the anterior wall and septum suggesting proximal LAD artery lesion. The reversible defect is >30% of the myocardium, indicating high risk. .. .. .. .. A. Reversible ischemia of large LAD area. A. Reversible apical perfusion defect. D. Normal rest and stress perfusion. A. Normal stress perfusion and normal left ventricular wall motion. .. A. Inferior wall infarction. Inferior wall infarction is indicated by the fixed perfusion deficit. .. A. Severe LAD artery lesion. .. C. Discharge home and continue medical management. The patient has normal perfusion without any ischemia, normal left ventricular wall motion, and normal EF. This indicates a low risk profile. .. B. Ischemia in LAD area. Cardiology Board Review References Gibbons, R.J., Balady, G.J., Bricker, J.T., et al. (2002) ACC/AHA 2002 Guideline Update for Exercise Testing: Summary Article. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation, 106: 1883–1892. Greenland, P., Alpert, J.S., Beller, G.A., et al. (2010) 2010 ACCF/AHA Guideline for Chapter 4 Assessment of Cardiovascular Risk in Asymptomatic Adults: Executive Summary. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guideline. Circulation, 122: 2748–2764. Echocardiography .. Which of the following manipulations will increase the echocardiographic frame rate (see Box 5.1)? A. Increase depth B. Increase transmit frequency C. Decrease sector angle D. Increase transmit power .. The lateral resolution increases with: A. Decreasing transducer diameter B. Reducing power C. Beam focusing D. Reducing transmit frequency .. Axial resolution can be improved by which of the following manipulations? A. Reducing beam diameter B. Beam focusing C. Reducing gain D. Increasing transmit frequency .. Which of the following is associated with continuous-wave Doppler compared with pulsed-wave Doppler? A. Aliasing B. Range specificity C. Ability to record higher velocities D. All of the above .. An intraoperative transesophageal echocardiogram (TEE) revealed mitral regurgitation (MR) with the following measurements: regurgitant jet area 4 cm2 , proximal isovelocity surface area (PISA) radius 0.8 cm at a Nyquist limit of 50 cm/s at a heart rate of 82 bpm and arterial blood pressure 80/40 mmHg (see Box 5.2). What does this represent? A. Mild MR B. Moderate MR C. Severe MR .. With one exception, for a given regurgitant volume all of the following result in a reduction in the jet size. Which is the exception? A. Fast heart rate B. Doubling the sector angle C. Increasing the imaging depth D. Increasing the blood pressure Cardiology Board Review, First Edition. Ramdas G. Pai, Padmini Varadarajan and Sudha M. Pai. © 2018 John Wiley & Sons, Ltd. Published 2018 by John Wiley & Sons, Ltd. Chapter 5 Cardiology Board Review .. A patient has an LV outflow tract (LVOT) velocity of 1 m/s, time velocity integral (TVI) of 25 cm, LVOT diameter of 2 cm, aortic transvalvular velocity of 1.5 m/s, and heart rate 70 bpm. What is the cardiac output of this patient? A. 5.5 L/min B. 4.5 L/min C. 6.3 L/min D. Cannot be determined based on the data given .. A patient with aortic stenosis (AS) has an LVOT diameter of 2 cm, LVOT velocity (V1) of 2.5 m/s, and transaortic valve velocity (V2) of 5 m/s; two-dimensional examination showed moderate systolic anterior motion (SAM) of the mitral leaflet. How would you describe the valvular AS in this patient? A. Mild B. Moderate C. Severe D. Cannot be calculated based on data given .. In a patient with isolated aortic regurgitation (AR), the following measurements were obtained: transmitral flow 80 cm3 /beat, flow across aortic valve 140 cm3 /beat, TVI of AR signal 100 cm. How would you describe the AR in this patient? A. Mild B. Moderate C. Severe D. Cannot be determined .. The presence of severe AR in a patient with mitral stenosis (MS) is likely to do which of the following to the calculated mitral valve area by the pressure half-time method? A. Overestimate the valve area B. Underestimate the valve area C. Have no effect .. What is this patient in Figure 5.11 likely to have? A. Severe AS B. Severe MR C. Severe pulmonary hypertension D. Mild AS .. For the patient in question above, the LVOT diameter was 2 cm and the LVOT velocity by pulse Doppler was 1 m/s. What is the aortic valve area by the continuity equation? A. 0.2 cm2 B. 0.3 cm2 C. 0.5 cm2 D. 0.8 cm2 .. Figure 5.13 is the continuous wave signal obtained from the pulmonary valve at the mid to proximal esophageal location. What is this patient likely to have? A. Wide-open pulmonary regurgitation (PR) B. Mild PR C. Severe valvular pulmonary stenosis (PS) D. Severe subvalvular PS 5 Echocardiography Chapter 5 Figure . Figure . .. The pulmonary vein flow shown in Figure 5.14 is indicative of what? A. Elevated LA pressure with normal end diastolic pressure (EDP) B. Elevated LA pressure with elevated EDP C. Abnormal LV relaxation with normal EDP D. Elevated LV EDP with normal LA pressure Cardiology Board Review Chapter 5 Figure . .. The mitral flow pattern shown in Figure 5.15 is suggestive of what? A. Normal LA pressure B. High LA pressure C. Atrial mechanical failure D. Abnormal LV relaxation with normal LA pressure Figure . 5 Echocardiography .. What condition does the patient in Figure 5.16 have? A. Mitral atresia B. Tricuspid atresia C. Transposition of great vessels with atrial baffle D. Epstein’s anomaly Chapter 5 Figure . .. Which of the following does the patient in Figure 5.17 have? A. Prominent Eustachian valve B. Ostium secundum ASD C. Ostium primum ASD D. Sinus venosus ASD .. What type of flow was recorded from the mid-esophageal position in Figure 5.18? A. Mitral flow B. Pulmonary vein flow C. Superior vena cava flow D. Flow across ASD .. The patient in Question 5.17 with secundum ASD has ASD dimensions of the defect 3 cm × 2 cm, TVI of flow across the defect is 39 cm, and heart rate of 70/s. What is the approximate shunt flow across the ASD? A. 12.8 L/min C. 7 L/min B. 3 L/min D. Cannot be calculated .. What is the cause of the patient’s mitral valve problem shown in Figure 5.20? A. Rheumatic heart disease B. Degenerative valve disease C. Fen–phen valvulopathy D. Ischemic heart disease Cardiology Board Review Chapter 5 Figure . Figure . 5 Echocardiography Chapter 5 Figure . .. Figure 5.21 shows a patient that may have all of the following except what? A. Atrial septal defect B. Wolf–Parkinson–White syndrome C. TR D. Bicuspid aortic valve .. The M-mode echocardiogram in Figure 5.22 is suggestive of what? A. Normal mitral valve motion C. Severe AR B. MS D. High LA pressure .. What is the image shown in Figure 5.23 suggestive of? A. Mitral annuloplasty B. Catheter in the coronary artery C. Biventricular pacemaker or implantable cardioverter-defibrillator (ICD) D. An artifact .. What is the structure denoted by the arrow in Figure 5.24? A. LA appendage B. Left lower pulmonary vein C. Left upper pulmonary vein D. Right lower pulmonary vein .. The patient shown in Figure 5.25 has what condition? A. Valvular AS B. Subvalvular AS C. Endocarditis D. Hypertrophic obstructive cardiomyopathy (HOCM) Figure . Figure . 5 Echocardiography Chapter 5 Figure . Figure . Cardiology Board Review Chapter 5 Figure . .. The cause of dyspnea in the patient in Figure 5.26 is likely to be due to what? A. Left heart failure B.