Advanced Cardiovascular Pathology and Clinical Implications Quiz

1. A young man with chronic hepatitis B and a history of intravenous drug abuse presents with fever, weight loss, bloody stools, right flank pain, tender hepatomegaly, and positive stool guaiac. A renal angiogram shows thrombosis of the right renal artery and focal, wedge-shaped areas of hypovascularity in the renal cortex. What is the most likely diagnosis?

IgA nephropathy

Aortic dissection

Acute pyelonephritis

Polyarteritis nodosa is a vasculitis of medium-sized muscular arteries commonly associated with hepatitis B infection. It can lead to thrombosis of renal arteries and cortical infarctions, causing flank pain and hematuria. Treatment involves corticosteroids and immunosuppressive agents.

Explanation

Polyarteritis nodosa is a vasculitis of medium-sized muscular arteries commonly associated with hepatitis B infection. It can lead to thrombosis of renal arteries and cortical infarctions, causing flank pain and hematuria. Treatment involves corticosteroids and immunosuppressive agents.

2. A pregnant woman at 31 weeks' gestation presents with a systolic murmur at the left lower sternal border and splitting S2, both of which are more pronounced with inspiration. What is the most likely cause of this finding?

*This murmur is Normal Physiologic Response in this pregnant patient.*This is likely a tricuspird regurgitation.

The presence of this murmur suggests mitral valve prolapse, a common condition in pregnant women.

The murmur is likely due to ventricular septal defect, which can lead to complications during pregnancy.

This murmur indicates aortic stenosis, a serious condition that requires immediate intervention.

During pregnancy, there are changes in the cardiovascular system that can lead to innocent systolic murmurs like tricuspid regurgitation. It is important to differentiate between normal physiological murmurs and pathological murmurs to avoid unnecessary interventions.

Explanation

During pregnancy, there are changes in the cardiovascular system that can lead to innocent systolic murmurs like tricuspid regurgitation. It is important to differentiate between normal physiological murmurs and pathological murmurs to avoid unnecessary interventions.

3. Patient with family history of Chronic renal failure in multiple relatives dies soon after developing severe headache at the back of the head. What is the most likely cause of death?

Chronic renal failure due to genetic predisposition

Stroke due to hypertension leading to cerebral hemorrhage

Brain tumor causing pressure and headache

Berry aneurysm is a common cause of death in patients with ADPKD due to hypertension being a significant risk factor. These aneurysms tend to rupture near the main cerebral artery, leading to sudden onset of severe headache and potential fatality.

Explanation

Berry aneurysm is a common cause of death in patients with ADPKD due to hypertension being a significant risk factor. These aneurysms tend to rupture near the main cerebral artery, leading to sudden onset of severe headache and potential fatality.

4. Guy's father died at the age of 30 due to 'Heart Problems'. He is 35 year-old and has had several episodes of syncope recently. Cardiac auscultation reveals a harsh-systolic ejecton murmur. Echocardiography shows assymetric interventricular septum hypertrophy. Left ventricular outflow obstruction is created by?

Tricuspid valve and Aortic valve

Right ventricle and Pulmonary artery

Pulmonary valve and Left atrium

This young male likely has Hypertrophic Cardiomyopathy. Outflow tract is likely obstructed by Mitral valve cusp and Interventricular septum. Systolic Anterior movement of Anterior leaflet of mitral valve results in abnormal contact with interventricular septum, leading to obstruction of outflow tract.

Explanation

This young male likely has Hypertrophic Cardiomyopathy. Outflow tract is likely obstructed by Mitral valve cusp and Interventricular septum. Systolic Anterior movement of Anterior leaflet of mitral valve results in abnormal contact with interventricular septum, leading to obstruction of outflow tract.

5. What is the significance of having a bicuspid valve in the aorta, leading to premature calcific aortic stenosis?

Having a bicuspid valve in the aorta has no impact on the development of aortic stenosis.

Individuals with a bicuspid valve in the aorta are more likely to develop calcific aortic stenosis later in life.

Aortic stenosis is more severe in patients with a tricuspid valve in the aorta compared to a bicuspid valve.

Patients with bicuspid aortic valves are at increased risk of developing premature calcific aortic stenosis compared to those with a tricuspid valve. Additionally, they are more prone to Infectious Endocarditis due to their unique valve structure.

Explanation

Patients with bicuspid aortic valves are at increased risk of developing premature calcific aortic stenosis compared to those with a tricuspid valve. Additionally, they are more prone to Infectious Endocarditis due to their unique valve structure.

6. Which vessels are most likely affected in an Obese smoker, who has intermittent pain in the left leg as he walks and gets better with rest?

Veins

Coronary arteries

Capillaries

Intermittent claudication when walking in an Obese/smoker usually indicates Peripheral artery disease due to atherosclerosis involving arteries, such as the popliteal artery. Veins and capillaries are less likely to be the primary vessels affected in this scenario.

Explanation

Intermittent claudication when walking in an Obese/smoker usually indicates Peripheral artery disease due to atherosclerosis involving arteries, such as the popliteal artery. Veins and capillaries are less likely to be the primary vessels affected in this scenario.

7. Why can a patient who had Strep.pharyngitis potentially die from excessive cardiovascular stress (like being pregnant)?

Food poisoning can cause cardiovascular complications by affecting blood pressure and heart rate.

Having a common cold can lead to cardiovascular stress due to the body working harder to fight off the infection.

Pneumonia can result in heart failure due to the inflammation of the lungs affecting cardiovascular function.

The correct answer highlights the specific complication of Rheumatic fever causing Mitral stenosis leading to potential heart failure under stress, while the incorrect answers provide unrelated causes of cardiovascular stress.

Explanation

The correct answer highlights the specific complication of Rheumatic fever causing Mitral stenosis leading to potential heart failure under stress, while the incorrect answers provide unrelated causes of cardiovascular stress.

8. How would you diagnose dilated cardiomyopathy?

By elevated levels of creatinine kinase-MB (CK-MB) in blood tests

By measuring pulmonary artery pressures via Swan-Ganz catheter insertion

By EKG findings showing ST segment elevation in all leads

The correct way to diagnose dilated cardiomyopathy involves assessing risk factors, excluding other causes of heart failure, and looking for specific indicators such as systolic pressure gradients. EKG findings, pulmonary artery pressures, and CK-MB levels are not typically used for diagnosis in this scenario.

Explanation

The correct way to diagnose dilated cardiomyopathy involves assessing risk factors, excluding other causes of heart failure, and looking for specific indicators such as systolic pressure gradients. EKG findings, pulmonary artery pressures, and CK-MB levels are not typically used for diagnosis in this scenario.

9. 75 year-old guy died in car accident. He is known to have a normal ECG, tolerant of moderate exercise, asymptomatic. Aortic valve is heavily calcified. What is the most likely process that preceded it?

Hyperparathyroidism.

Metastatic calcification.

Lung cancer.

Dystrophic calcification is usually associated with damaged tissue/necrosis, as in this case of the heavily calcified aortic valve. Metastatic calcification is associated with hypercalcemia, which was not indicated in the question. Hyperparathyroidism is also not the most likely process in this scenario. Lung cancer was not mentioned in the question or explanation.

Explanation

Dystrophic calcification is usually associated with damaged tissue/necrosis, as in this case of the heavily calcified aortic valve. Metastatic calcification is associated with hypercalcemia, which was not indicated in the question. Hyperparathyroidism is also not the most likely process in this scenario. Lung cancer was not mentioned in the question or explanation.

10. A patient with UTI didn't take antibiotics for her infection. Later on she presents with increased BUN/Creatinine, Oliguria. Why would you check her ECG and what findings would you see?

The patient may have developed a urinary tract obstruction which caused the increased BUN/Creatinine, Oliguria, and ECG changes.

The patient is likely to have heart failure leading to a decreased BUN/Creatinine ratio.

The patient may be experiencing a flare-up of her UTI, causing symptoms of renal failure and ECG abnormalities.

11. What type of murmur is likely to be auscultated in a patient with bacterial endocarditis?

Systolic ejection murmur

Diastolic rumbling murmur

Continuous machinery murmur

Microemboli from the valvular vegetations of bacterial endocarditis are the most common cause of subungual splinter hemorrhages. Janeway lesions, small erythematous, macular, hemorrhagic, non-tender lesions on the palms and soles, also indicate possible bacterial endocarditis.

Explanation

Microemboli from the valvular vegetations of bacterial endocarditis are the most common cause of subungual splinter hemorrhages. Janeway lesions, small erythematous, macular, hemorrhagic, non-tender lesions on the palms and soles, also indicate possible bacterial endocarditis.

12. Why standing suddenly from supine would increase harsh-systolic murmur in HCM (Autosomal Dominant, with variable expressivity - they can show you an image of heart with Asymmetric hypertrophy of Interventricular septum), while Phenylephrine would Decrease the murmur?

B) Phenylephrine would increase the intensity of the murmur in HCM

A) Standing up suddenly from supine would decrease the harsh-systolic murmur in HCM

C) Lying down from standing position would increase the harsh-systolic murmur in HCM

13. Which condition is diagnosed by a combination of a ventricular septal defect with an aorta that overrides the septal defect, stenosis of the pulmonic valve, and increased thickness of the right ventricle?

Atrial septal defect

Coarctation of the aorta

Patent ductus arteriosus

The combination of features described in the question is characteristic of Tetralogy of Fallot, a congenital heart defect. The other conditions listed do not present with the specific combination of defects mentioned in the question.

Explanation

The combination of features described in the question is characteristic of Tetralogy of Fallot, a congenital heart defect. The other conditions listed do not present with the specific combination of defects mentioned in the question.

14. Patient presents with dyspnea on exertion. She is 48 and is concerned her problem could be due to her family history of MI. She is obese and smokes. What type of angina is she most likely experiencing?

Chronic Angina

Prinzmetal Angina

Unstable Angina

This patient's symptoms align with stable angina, which is chest pain that occurs with exertion but improves with rest. Prinzmetal angina is chest pain at rest, while unstable angina is prolonged chest pain at rest.

Explanation

This patient's symptoms align with stable angina, which is chest pain that occurs with exertion but improves with rest. Prinzmetal angina is chest pain at rest, while unstable angina is prolonged chest pain at rest.

15. Which of the following describes the most likely outcome for a patient presenting with migratory polyarthritis, fever, malaise, new heart murmur, friction rub, and a painless nodule following a severe sore throat with elevated anti-streptolysin O (ASO) titer?

Development of mitral valve stenosis over the next few months

Development of mitral valve stenosis over many months to years

Fatality from acute myocarditis secondary to heart failure

Most cases of acute rheumatic fever will not result in any complications, and if complications were to occur, the most likely cause of fatality would be heart failure secondary to myocarditis.

Explanation

Most cases of acute rheumatic fever will not result in any complications, and if complications were to occur, the most likely cause of fatality would be heart failure secondary to myocarditis.

16. 70-year-old woman has a long history of metastatic colon cancer, and she donates her body for use in medical school anatomy courses. At death, the body is emaciated and cachectic, and gross dissection reveals small fibrin deposits arranged around the line of closure of the leaflets of the mitral valve. The valvular lesions most likely represent.

Aortic stenosis

*Nonbacterial thrombotic (marantic) endocarditis.

Rheumatic heart disease

Infective endocarditis

The valvular lesions in this scenario are most likely due to nonbacterial thrombotic (marantic) endocarditis. This type of endocarditis is typically associated with chronic wasting diseases such as advanced cancer. The other options listed (infective endocarditis, rheumatic heart disease, aortic stenosis) are less likely based on the clinical presentation described in the question.

Explanation

The valvular lesions in this scenario are most likely due to nonbacterial thrombotic (marantic) endocarditis. This type of endocarditis is typically associated with chronic wasting diseases such as advanced cancer. The other options listed (infective endocarditis, rheumatic heart disease, aortic stenosis) are less likely based on the clinical presentation described in the question.

17. In a patient who develops HF resistant to all treatments after cardiac surgery, presents with paradoxical rise in jugular venous pressure on inspiration (Kussmaul sign), Pulsus Paradoxus, and Pericardial Knock on auscultation, what is the most likely diagnosis?

Dilated Cardiomyopathy

Aortic Stenosis

Acute Myocardial Infarction

18. What is the most common cause of lethal cardiac arrest in CAD-associated sudden cardiac death (SCD)?

Hemorrhagic stroke due to ruptured blood vessels in the brain

Pulmonary embolism resulting from blood clots traveling to the lungs

Atherosclerosis leading to complete blockage of coronary arteries

In CAD-associated sudden cardiac death, ventricular arrhythmia plays a crucial role in causing lethal cardiac arrest. It is important to differentiate between various causes such as atherosclerosis, hemorrhagic stroke, and pulmonary embolism which do not directly lead to cardiac arrest in this context.

Explanation

In CAD-associated sudden cardiac death, ventricular arrhythmia plays a crucial role in causing lethal cardiac arrest. It is important to differentiate between various causes such as atherosclerosis, hemorrhagic stroke, and pulmonary embolism which do not directly lead to cardiac arrest in this context.

19. What histologic finding is likely in a patient with a mid-diastolic rumbling murmur best heard at the apex, positional dyspnea, a large pedunculated mass attached to the left atrium, fever, and weight loss?

Acute rheumatic fever with fibrinous pericarditis and vegetations on the heart valves

Cardiac fibroma with fibrous tissue and scattered multinucleated giant cells

Cor triatriatum sinister with a membrane obstructing the left atrium

The patient's presentation is most consistent with an atrial myxoma, characterized by a large pedunculated mass attached to the left atrium. The histologic findings often include scattered cells within a mucopolysaccharide stroma and excessive vascular growth with hemorrhaging. This differentiates it from the other incorrect options provided.

Explanation

The patient's presentation is most consistent with an atrial myxoma, characterized by a large pedunculated mass attached to the left atrium. The histologic findings often include scattered cells within a mucopolysaccharide stroma and excessive vascular growth with hemorrhaging. This differentiates it from the other incorrect options provided.

20. Why should you avoid using milrinone to increase contractility of the heart in a hypotensive patient?

Milrinone can only be used safely in hypotensive patients.

Milrinone increases blood pressure in hypotensive patients.

Milrinone has no effect on blood pressure in hypotensive patients.

Milrinone, as a phosphodiesterase inhibitor, can cause vasodilation in vascular smooth muscle due to increased cAMP levels, which can worsen hypotension in patients. This is why milrinone should be avoided in hypotensive patients to prevent further decrease in blood pressure.

Explanation

Milrinone, as a phosphodiesterase inhibitor, can cause vasodilation in vascular smooth muscle due to increased cAMP levels, which can worsen hypotension in patients. This is why milrinone should be avoided in hypotensive patients to prevent further decrease in blood pressure.

21. Which part of the ECG is most likely to be affected by a pacemaker?

Pacemaker can cause abnormalities in the P wave.

*Pacemaker(Just like fascicular block,R or L BBB)can>Widened QRS(>120msec)

Pacemaker can alter the PR interval on the ECG.

Pacemaker can affect the T wave morphology on the ECG.

Pacemakers primarily affect the QRS complex on an ECG, leading to a widened QRS complex (>120 msec). While pacemakers can impact other parts of the ECG, the most common manifestation is a widened QRS complex.

Explanation

Pacemakers primarily affect the QRS complex on an ECG, leading to a widened QRS complex (>120 msec). While pacemakers can impact other parts of the ECG, the most common manifestation is a widened QRS complex.

22. Patient has been treated by a drug for atrial fibrilation with rapid ventricular response + Systolic cardiac dysfunction. Patient presents with Severe GI upset + Blurry vision. Why might the patient have HYPERKALEMIA? Why might the patient have Bradycardia? How can this drug cause Ventricular Tachycardia/Fibrillation? What are some classic toxicity manifestations? How would you manage toxicity? What ECG changes can be seen?

Digoxin does not influence the AV node or cause AV block.

Digoxin toxicity does not present with any gastrointestinal symptoms.

Spironolactone is the main cause of hyperkalemia in this scenario.

23. What kind of Vegetations are you likely to see in a patient with SLE and Libman-sacks endocarditis?

No vegetations are seen in Libman-sacks endocarditis.

Vegetations are only seen on the Tricuspid valve.

Large, friable vegetations on the Aortic valve.

The correct answer describes the characteristic small, verrucous vegetations typically seen in Libman-sacks endocarditis, especially on both sides of the Mitral valve. It contrasts with large, friable vegetations seen in infective endocarditis.

Explanation

The correct answer describes the characteristic small, verrucous vegetations typically seen in Libman-sacks endocarditis, especially on both sides of the Mitral valve. It contrasts with large, friable vegetations seen in infective endocarditis.

24. What is the relevance of Myxomatous changes?

Myxomatous changes in the media of large arteries lead to improved arterial strength and elasticity.

Myxomatous degeneration is primarily caused by bacterial infections.

Myxomatous changes refer to an increase in tissue function and activity.

Myxomatous changes typically refer to a decrease in tissue function and can lead to various complications, including aortic aneurysms and mitral valve insufficiency. They are not associated with an increase in tissue function or improved arterial strength. Additionally, myxomatous degeneration is not caused by bacterial infections but is more commonly linked to genetic disorders like Marfan syndrome.

Explanation

Myxomatous changes typically refer to a decrease in tissue function and can lead to various complications, including aortic aneurysms and mitral valve insufficiency. They are not associated with an increase in tissue function or improved arterial strength. Additionally, myxomatous degeneration is not caused by bacterial infections but is more commonly linked to genetic disorders like Marfan syndrome.

25. What is the difference between myocardial stunning, myocardial hibernation, and ischemic preconditioning?

Myocardial Hibernation is a temporary condition that resolves on its own.

Myocardial stunning results in irreversible loss of contractile function.

Ischemic preconditioning is a form of heart failure.

Myocardial stunning and hibernation both result in reversible loss of contractile function, while ischemic preconditioning is a protective mechanism against infarction.

Explanation

Myocardial stunning and hibernation both result in reversible loss of contractile function, while ischemic preconditioning is a protective mechanism against infarction.

26. What is the earliest lesion of atherosclerosis and how does atherosclerotic plaque form?

Accumulation of cholesterol in the tunica adventitia

Calcium deposits in the vessel walls

Formation of fibrous plaques in the tunica media

Atherosclerotic plaque formation involves endothelial damage, denudation of vascular endothelium, aggregation of platelets, release of PDGF, migration of Smooth muscle cells to INTIMA, proliferation, and narrowing of vessel lumen.

Explanation

Atherosclerotic plaque formation involves endothelial damage, denudation of vascular endothelium, aggregation of platelets, release of PDGF, migration of Smooth muscle cells to INTIMA, proliferation, and narrowing of vessel lumen.

27. What is the characteristic finding in patients with severe left ventricular dysfunction?

Hypertension - High blood pressure

Bradycardia - Abnormally slow heart rate

Tachycardia - Abnormally rapid heart rate

In patients with severe left ventricular dysfunction, pulsus alterans is a hallmark finding indicating systolic dysfunction, not necessarily related to tachycardia, hypertension, or bradycardia.

Explanation

In patients with severe left ventricular dysfunction, pulsus alterans is a hallmark finding indicating systolic dysfunction, not necessarily related to tachycardia, hypertension, or bradycardia.

28. 47-y/o man has hypertension in the upper extremities and weak pulses in the lower extremities (Brachial-femoral delay). Why might he have rib notching on X-ray and what complications is he at increased risk for?

Rib notching is a common occurrence in individuals with scoliosis. Complications may include spinal deformities and chronic back pain.

The patient might have developed pleural effusion leading to rib notching on X-ray. Complications include pneumonia and pleurisy.

The rib notching is due to a lung infection such as tuberculosis. Complications involve respiratory distress and lung scarring.

The correct answer explains the relationship between coarctation of the aorta, rib notching, and the potential complications the patient is at increased risk for.

Explanation

The correct answer explains the relationship between coarctation of the aorta, rib notching, and the potential complications the patient is at increased risk for.

29. Medial Calcific Sclerosis-Monckeberg's arteriosclerosis doesn't involve intimal thickening and doesn't limit the blood flow, but what is the clinical relevance?

The calcifications in Monckeberg's arteriosclerosis are only visible on ultrasound imaging.

Monckeberg's arteriosclerosis involves intimal thickening and restricts blood flow significantly.

High levels of calcification in Monckeberg's arteriosclerosis are indicative of low calcium levels in the blood.