CSC Cardiac Subspecialty 3 — Questions and Answers
Question 1: A 58-year-old with severe aortic stenosis (AVA 0.7 cm², mean gradient 52 mmHg) is asymptomatic. Which finding would prompt intervention?
- Heart rate >80 bpm at rest
- LV ejection fraction <50% on serial echocardiography (Correct answer)
- Moderate mitral regurgitation on the same echocardiogram
- Resting blood pressure of 145/88 mmHg
Correct answer: LV ejection fraction <50% on serial echocardiography
Asymptomatic severe AS with LVEF <50% is a Class I indication for valve replacement due to evidence of LV dysfunction.
Question 2: Which finding on coronary angiography is most consistent with a fractional flow reserve (FFR) value of <0.80, indicating hemodynamically significant stenosis?
- 50% diameter stenosis in the LAD with TIMI 3 flow
- 40% diameter stenosis in a dominant RCA
- 80% diameter stenosis in a large obtuse marginal branch supplying viable myocardium (Correct answer)
- 30% ostial stenosis of the left main coronary artery
Correct answer: 80% diameter stenosis in a large obtuse marginal branch supplying viable myocardium
An 80% stenosis in a territory supplying viable myocardium is most likely to produce a pressure drop resulting in FFR <0.80.
Question 3: A patient with long QT syndrome type 1 (LQT1) presents after a near-syncopal episode during swimming. What is the most appropriate management?
- Restrict activity only and avoid QT-prolonging drugs
- Initiate beta-blocker therapy and restrict swimming (Correct answer)
- Immediate ICD implantation without beta-blocker trial
- Prescribe flecainide for arrhythmia suppression
Correct answer: Initiate beta-blocker therapy and restrict swimming
Beta-blockers are highly effective in LQT1 and mandatory after a symptomatic event; swimming is a specific trigger and should be restricted.
Question 4: Which statement about cardiac MRI in patients with known or suspected myocarditis is MOST accurate?
- Late gadolinium enhancement in a subendocardial pattern confirms myocarditis
- T2-weighted imaging can detect myocardial edema, reflecting active inflammation (Correct answer)
- Cardiac MRI should not be performed within 14 days of symptom onset
- Absence of LGE excludes myocarditis with high specificity
Correct answer: T2-weighted imaging can detect myocardial edema, reflecting active inflammation
T2-weighted CMR detects myocardial edema and is a key component of the Lake Louise criteria for myocarditis diagnosis.
Question 5: A patient develops ventricular fibrillation during a diagnostic coronary angiogram. After successful defibrillation, coronary arteries are found to be normal. What is the most likely diagnosis?
- Takotsubo cardiomyopathy
- Brugada syndrome
- Coronary vasospasm causing Prinzmetal angina (Correct answer)
- Left ventricular non-compaction
Correct answer: Coronary vasospasm causing Prinzmetal angina
Coronary vasospasm (Prinzmetal variant angina) can cause VF during angiography due to transient occlusive spasm even in angiographically normal arteries.
Question 6: In a patient with symptomatic heart failure with preserved ejection fraction (HFpEF, EF 58%), which intervention has the strongest evidence for reducing hospitalizations?
- ACE inhibitor therapy
- Aldosterone antagonist (spironolactone)
- SGLT2 inhibitor (empagliflozin or dapagliflozin) (Correct answer)
- Hydralazine-nitrate combination
Correct answer: SGLT2 inhibitor (empagliflozin or dapagliflozin)
EMPEROR-Preserved and DELIVER trials demonstrated significant reduction in HF hospitalizations with SGLT2 inhibitors in HFpEF.
Question 7: Which congenital heart defect is most commonly associated with Down syndrome (trisomy 21)?
- Bicuspid aortic valve
- Atrioventricular septal defect (AVSD) (Correct answer)
- Coarctation of the aorta
- Transposition of the great arteries
Correct answer: Atrioventricular septal defect (AVSD)
Atrioventricular septal defects (complete AV canal) are the most common congenital cardiac anomaly in patients with Down syndrome, occurring in ~40%.
CSC Cardiac Subspecialty 3
A 58-year-old with severe aortic stenosis (AVA 0.7 cm², mean gradient 52 mmHg) is asymptomatic.
Which finding would prompt intervention?