CSC Case Studies & Practical Application 5 — Questions and Answers
Question 1: A 67-year-old man post-anterior STEMI develops new hypotension, elevated JVP, clear lung fields, and new holosystolic murmur. Echo shows a ventricular septal defect. What is the next best step?
- Emergent PCI of the infarct artery
- Intra-aortic balloon pump and emergent surgical VSD repair (Correct answer)
- Diuresis and vasodilator therapy
- Repeat thrombolysis
Correct answer: Intra-aortic balloon pump and emergent surgical VSD repair
Post-MI VSD with cardiogenic shock requires hemodynamic stabilization with IABP and emergent surgical repair, as mortality is very high without prompt intervention.
Question 2: A 60-year-old woman with known ATTR cardiac amyloidosis presents with progressive HFpEF and atrial fibrillation. What therapy has been shown to improve survival in transthyretin amyloid cardiomyopathy?
- ACE inhibitors
- Tafamidis (Correct answer)
- Sacubitril/valsartan
- Ivabradine
Correct answer: Tafamidis
Tafamidis stabilizes transthyretin tetramers and has demonstrated significant reductions in cardiovascular mortality and hospitalizations in ATTR cardiomyopathy (ATTR-ACT trial).
Question 3: A 55-year-old man with non-ischemic cardiomyopathy (EF 28%) on optimal GDMT develops NSVT on Holter monitoring. He has no syncope. What is the primary indication for ICD implantation in this patient?
- NSVT on Holter is the primary indication
- EF ≤35% despite ≥3 months of GDMT is the primary indication (Correct answer)
- Positive EP study result
- QRS duration >130 ms
Correct answer: EF ≤35% despite ≥3 months of GDMT is the primary indication
ICD implantation is indicated for primary prevention of SCD in non-ischemic cardiomyopathy when EF remains ≤35% after ≥3 months of optimal GDMT, regardless of NSVT.
Question 4: A 73-year-old woman presents with dyspnea. Right heart catheterization shows PCWP 28 mmHg, mPAP 42 mmHg, PVR 2.1 WU, and cardiac output 3.8 L/min. What type of pulmonary hypertension does she have?
- Group 1: Pulmonary arterial hypertension
- Group 2: PH due to left heart disease (Correct answer)
- Group 3: PH due to lung disease
- Group 4: Chronic thromboembolic PH
Correct answer: Group 2: PH due to left heart disease
Elevated PCWP (>15 mmHg) with elevated mPAP defines Group 2 pulmonary hypertension due to left heart disease, the most common cause of PH.
Question 5: A 49-year-old man undergoes PCI of the RCA with a drug-eluting stent. Two weeks later he requires urgent tooth extraction. What antiplatelet strategy is most appropriate?
- Stop both aspirin and P2Y12 inhibitor 5 days before procedure
- Continue both aspirin and P2Y12 inhibitor throughout the dental procedure (Correct answer)
- Stop P2Y12 inhibitor only and continue aspirin
- Defer extraction until 12 months of DAPT is complete
Correct answer: Continue both aspirin and P2Y12 inhibitor throughout the dental procedure
Within 3–6 months of DES implantation, DAPT should not be interrupted for minor surgical procedures; continuing both agents during tooth extraction is acceptable.
Question 6: A 38-year-old woman with no prior cardiac history presents with pleuritic chest pain, ST elevations in multiple leads without reciprocal changes, and elevated troponin. Echo is normal. What is the most likely diagnosis and first-line treatment?
- STEMI; emergent PCI
- Acute pericarditis; aspirin and colchicine (Correct answer)
- Type 2 MI; treat underlying cause
- Myocarditis; IV immunoglobulin
Correct answer: Acute pericarditis; aspirin and colchicine
Diffuse ST elevation without reciprocal changes, pleuritic chest pain, and normal wall motion strongly suggest acute pericarditis, treated with aspirin plus colchicine.
Question 7: A 64-year-old man with coronary artery disease on aspirin and clopidogrel presents with melena and hemoglobin of 7.5 g/dL. EGD reveals a bleeding peptic ulcer treated with endoscopic hemostasis. When should antiplatelet therapy be resumed?
- Never; permanently discontinue DAPT
- After 4–8 weeks when ulcer heals completely
- Resume aspirin within 3–5 days; resume P2Y12 within 5–7 days after hemostasis (Correct answer)
- Wait at least 6 months before restarting any antiplatelet
Correct answer: Resume aspirin within 3–5 days; resume P2Y12 within 5–7 days after hemostasis
After successful endoscopic hemostasis, aspirin can typically be resumed within 3–5 days and the P2Y12 inhibitor within 5–7 days, given high ischemic risk, alongside a PPI.
CSC Case Studies & Practical Application 5
A 67-year-old man post-anterior STEMI develops new hypotension, elevated JVP, clear lung fields, and new holosystolic murmur.
Echo shows a ventricular septal defect.
What is the next best step?