CSC Cardiac Subspecialty Certification 3 — Questions and Answers
Question 1: A patient presents with acute inferior STEMI. Which lead pattern is MOST specific for right ventricular involvement?
- ST elevation in V1–V4
- ST elevation in lead III > lead II
- ST elevation in V4R (Correct answer)
- ST depression in V1–V2
Correct answer: ST elevation in V4R
ST elevation in lead V4R (right-sided lead) is the most sensitive and specific marker for right ventricular MI.
Question 2: In the management of acute decompensated heart failure with cardiogenic shock, which hemodynamic profile (Forrester classification) defines 'cold and wet'?
- Low CI, low PCWP
- Low CI, high PCWP (Correct answer)
- Normal CI, high PCWP
- High CI, low PCWP
Correct answer: Low CI, high PCWP
The 'cold and wet' profile (Forrester Class IV) is defined by low cardiac index (<2.2 L/min/m²) and elevated PCWP (>18 mmHg), reflecting reduced perfusion and congestion.
Question 3: Which finding on cardiac catheterization is diagnostic of constrictive pericarditis versus restrictive cardiomyopathy?
- Elevated right atrial pressure
- Discordant ventricular pressure changes with respiration (Correct answer)
- Equalization of diastolic pressures
- Prominent Y descent on RA tracing
Correct answer: Discordant ventricular pressure changes with respiration
Discordant interventricular pressure changes during respiration (RV pressure rises while LV pressure falls with inspiration) is the hemodynamic hallmark of constrictive pericarditis.
Question 4: A patient with dilated cardiomyopathy (LVEF 28%) and LBBB (QRS 155 ms) is on maximally tolerated medical therapy. Which device therapy has the STRONGEST evidence for mortality reduction?
- Implantable cardioverter-defibrillator alone
- Cardiac resynchronization therapy with defibrillator (CRT-D) (Correct answer)
- Cardiac resynchronization therapy without defibrillator (CRT-P)
- Wearable cardioverter-defibrillator
Correct answer: Cardiac resynchronization therapy with defibrillator (CRT-D)
CRT-D is indicated for LVEF ≤35%, LBBB with QRS ≥150 ms on GDMT, providing both resynchronization benefit and sudden death protection.
Question 5: Which medication is CONTRAINDICATED in a patient with severe aortic stenosis presenting with acute pulmonary edema?
- IV furosemide
- IV nitroglycerin (Correct answer)
- IV morphine sulfate
- Supplemental oxygen
Correct answer: IV nitroglycerin
Nitroglycerin causes preload and afterload reduction; in severe AS, reducing preload can precipitate severe hypotension as fixed obstruction limits compensatory cardiac output increase.
Question 6: A patient has a 12-lead ECG showing delta waves, short PR interval, and wide QRS. He develops rapid atrial fibrillation. Which drug is CONTRAINDICATED?
- Procainamide
- Ibutilide
- IV adenosine (Correct answer)
- DC cardioversion
Correct answer: IV adenosine
Adenosine (and AV-nodal blocking agents like digoxin, verapamil, diltiazem, and beta-blockers) are contraindicated in WPW with AF as they can accelerate conduction down the accessory pathway, precipitating ventricular fibrillation.
Question 7: Which echocardiographic parameter BEST differentiates Grade I diastolic dysfunction from a normal diastolic function pattern in a patient with a preserved LVEF?
- Mitral E/A ratio <0.8 with average E/e' ≤14 (Correct answer)
- Tricuspid regurgitation velocity >2.8 m/s
- Left atrial volume index >34 mL/m²
- Isovolumetric relaxation time >100 ms
Correct answer: Mitral E/A ratio <0.8 with average E/e' ≤14
Grade I diastolic dysfunction is characterized by impaired relaxation with E/A <0.8 and average E/e' ≤14, reflecting decreased LV relaxation without elevated filling pressures.
CSC Cardiac Subspecialty Certification 3
A patient presents with acute inferior STEMI.
Which lead pattern is MOST specific for right ventricular involvement?