CSC CSC 3 — Questions and Answers
Question 1: A patient with acute ST-elevation myocardial infarction (STEMI) presents 2 hours after symptom onset. The cath lab is available. What is the preferred reperfusion strategy?
- Fibrinolytic therapy followed by angiography in 3–24 hours
- Primary PCI within 90 minutes of first medical contact (Correct answer)
- Conservative management with anticoagulation alone
- Emergency CABG
Correct answer: Primary PCI within 90 minutes of first medical contact
Primary PCI is the preferred reperfusion strategy for STEMI when door-to-balloon time can be achieved within 90 minutes of first medical contact.
Question 2: Which valve lesion is most likely to produce a crescendo-decrescendo systolic murmur that radiates to the carotid arteries?
- Mitral regurgitation
- Tricuspid stenosis
- Aortic stenosis (Correct answer)
- Pulmonary regurgitation
Correct answer: Aortic stenosis
Aortic stenosis produces a harsh crescendo-decrescendo (diamond-shaped) systolic ejection murmur best heard at the right upper sternal border with radiation to the carotids.
Question 3: A 72-year-old woman with severe symptomatic aortic stenosis is deemed high surgical risk. Which intervention is most appropriate?
- Medical management with diuretics and nitrates
- Balloon aortic valvuloplasty as definitive therapy
- Transcatheter aortic valve replacement (TAVR) (Correct answer)
- Watchful waiting with repeat echo in 6 months
Correct answer: Transcatheter aortic valve replacement (TAVR)
TAVR is the preferred intervention for severe symptomatic AS in high or prohibitive surgical risk patients and has shown non-inferiority to SAVR even in intermediate-risk patients.
Question 4: Which finding on a right heart catheterization would suggest pulmonary arterial hypertension (PAH) rather than pulmonary venous hypertension (PVH)?
- Mean PAP >25 mmHg with PCWP >15 mmHg
- Mean PAP >25 mmHg with PCWP ≤15 mmHg (Correct answer)
- Elevated right atrial pressure with low cardiac output
- High PCWP with normal pulmonary vascular resistance
Correct answer: Mean PAP >25 mmHg with PCWP ≤15 mmHg
PAH is defined by mean PAP >25 mmHg with PCWP ≤15 mmHg and elevated pulmonary vascular resistance (>3 Wood units), distinguishing it from left heart disease-related PVH.
Question 5: A patient develops complete heart block after inferior STEMI. Which vessel is most likely occluded?
- Left anterior descending artery
- Left circumflex artery
- Right coronary artery (Correct answer)
- Diagonal branch
Correct answer: Right coronary artery
The RCA supplies the AV node in ~90% of patients; inferior STEMI from RCA occlusion commonly causes AV nodal blocks including complete heart block.
Question 6: Which medication has been shown to reduce hospitalizations for heart failure in patients with HFrEF through neprilysin inhibition combined with ARB blockade?
- Carvedilol
- Spironolactone
- Sacubitril/valsartan (Entresto) (Correct answer)
- Ivabradine
Correct answer: Sacubitril/valsartan (Entresto)
Sacubitril/valsartan (ARNI) inhibits neprilysin (increasing natriuretic peptides) and blocks the RAAS, reducing cardiovascular death and HF hospitalizations vs. enalapril in PARADIGM-HF.
Question 7: A 45-year-old woman presents with a mid-systolic click followed by a late systolic murmur at the apex. Which diagnosis is most likely?
- Hypertrophic obstructive cardiomyopathy
- Mitral valve prolapse (Correct answer)
- Aortic stenosis
- Ventricular septal defect
Correct answer: Mitral valve prolapse
Mitral valve prolapse classically presents with a mid-systolic click (billowing of leaflets into LA) followed by a late systolic murmur of mitral regurgitation.
CSC CSC 3
A patient with acute ST-elevation myocardial infarction (STEMI) presents 2 hours after symptom onset.
The cath lab is available.
What is the preferred reperfusion strategy?