CSC Cardiac Subspecialty 2 — Questions and Answers
Question 1: A patient with hypertrophic obstructive cardiomyopathy (HOCM) has a dynamic outflow tract gradient of 55 mmHg at rest. Which maneuver would INCREASE the gradient?
- Squatting
- Passive leg raise
- Valsalva maneuver (strain phase) (Correct answer)
- Handgrip exercise
Correct answer: Valsalva maneuver (strain phase)
The Valsalva strain phase reduces venous return, decreasing LV volume and worsening LVOT obstruction in HOCM.
Question 2: In the PARTNER trial, transcatheter aortic valve replacement (TAVR) compared to surgical AVR showed which key finding in intermediate-risk patients at 2 years?
- TAVR had significantly higher stroke rates
- TAVR and SAVR had similar rates of death and disabling stroke (Correct answer)
- SAVR had significantly lower rates of paravalvular leak
- TAVR had significantly higher rates of permanent pacemaker implantation with no mortality difference
Correct answer: TAVR and SAVR had similar rates of death and disabling stroke
PARTNER 2A demonstrated non-inferiority of TAVR versus SAVR for the primary endpoint of death or disabling stroke in intermediate-risk patients.
Question 3: A 65-year-old presents with new-onset atrial fibrillation and a CHA₂DS₂-VASc score of 3. Which anticoagulation strategy is most appropriate?
- Aspirin 81 mg daily
- No anticoagulation needed below score of 4
- Oral anticoagulation with a DOAC or warfarin (Correct answer)
- Dual antiplatelet therapy with aspirin and clopidogrel
Correct answer: Oral anticoagulation with a DOAC or warfarin
A CHA₂DS₂-VASc score ≥2 in men (≥3 in women) warrants oral anticoagulation to reduce stroke risk in AF.
Question 4: On right heart catheterization, a patient has PCWP of 28 mmHg, PA mean of 42 mmHg, and cardiac output of 3.1 L/min. What is the transpulmonary gradient and what does it suggest?
- TPG = 14 mmHg, suggesting isolated post-capillary pulmonary hypertension
- TPG = 14 mmHg, suggesting combined pre- and post-capillary pulmonary hypertension (Correct answer)
- TPG = 70 mmHg, suggesting pulmonary arterial hypertension
- TPG = 6 mmHg, suggesting normal pulmonary vascular resistance
Correct answer: TPG = 14 mmHg, suggesting combined pre- and post-capillary pulmonary hypertension
TPG = mPAP − PCWP = 42 − 28 = 14 mmHg; a TPG >12 mmHg with elevated PCWP indicates combined pre- and post-capillary pulmonary hypertension.
Question 5: Which echocardiographic finding is most consistent with cardiac tamponade physiology?
- Dilated inferior vena cava with >50% inspiratory collapse
- Right ventricular diastolic collapse and respiratory variation in mitral inflow >25% (Correct answer)
- Left atrial enlargement with E/A ratio >2
- Septal bounce with respiratory variation in tricuspid inflow
Correct answer: Right ventricular diastolic collapse and respiratory variation in mitral inflow >25%
RV diastolic collapse and >25% respiratory variation in mitral inflow velocities are classic echocardiographic signs of tamponade.
Question 6: A patient with dilated cardiomyopathy (EF 28%) remains symptomatic on maximally tolerated doses of ACE inhibitor and beta-blocker. QRS duration is 162 ms with LBBB morphology. What is the next best step?
- Add digoxin for additional rate control
- Refer for ICD implantation only
- Refer for cardiac resynchronization therapy with defibrillator (CRT-D) (Correct answer)
- Increase diuretic dose and reassess in 3 months
Correct answer: Refer for cardiac resynchronization therapy with defibrillator (CRT-D)
CRT-D is a Class I indication in patients with EF ≤35%, LBBB, QRS ≥150 ms, and NYHA class II-IV symptoms despite GDMT.
Question 7: During exercise stress testing, which hemodynamic response is considered abnormal and associated with increased cardiovascular risk?
- Heart rate increase of 20 bpm per MET achieved
- Systolic blood pressure rise to 195 mmHg at peak exercise
- Failure of systolic blood pressure to rise or a drop of >10 mmHg from baseline (Correct answer)
- Diastolic blood pressure rise to 90 mmHg at peak exercise
Correct answer: Failure of systolic blood pressure to rise or a drop of >10 mmHg from baseline
Exercise-induced hypotension (failure to rise or drop >10 mmHg) indicates severe ischemia or LV dysfunction and is associated with high cardiovascular risk.
CSC Cardiac Subspecialty 2
A patient with hypertrophic obstructive cardiomyopathy (HOCM) has a dynamic outflow tract gradient of 55 mmHg at rest.
Which maneuver would INCREASE the gradient?