Cardiovascular Disease Flashcards

A 58-year-old man with hypertrophic obstructive cardiomyopathy (HOCM) presents with worsening dyspnea and presyncope. Echo shows LVOT gradient of 70 mmHg at rest. He is on metoprolol succinate 200 mg daily. Which intervention is MOST appropriate if symptoms persist despite optimal medical therapy and he is found to have a single dominant septal perforator supplying the hypertrophied septum?

Answer: Alcohol septal ablation

Alcohol septal ablation (ASA) is preferred when anatomy is suitable — specifically, when a dominant septal perforator clearly supplies the target area of hypertrophy, as confirmed by myocardial contrast echocardiography. Surgical myectomy is generally preferred for younger patients and those with complex anatomy, but ASA is anatomically ideal here. Dual-chamber pacing is no longer recommended as primary therapy (insufficient gradient reduction). Disopyramide can augment medical therapy but is not the answer when catheter-based intervention is anatomically optimal and medical therapy has already been maximized.

A 44-year-old woman with systemic lupus erythematosus presents with acute decompensated heart failure. Echo shows EF 20%, global hypokinesis, and a small pericardial effusion. Troponin is mildly elevated. Endomyocardial biopsy shows lymphocytic infiltration with myocyte necrosis. Anti-dsDNA is 1:640. Which treatment strategy is MOST likely to improve cardiac function?

Answer: High-dose intravenous methylprednisolone plus azathioprine

This patient has biopsy-proven lupus myocarditis, a distinct entity from viral or idiopathic myocarditis. Unlike most myocarditis where immunosuppression is not routinely recommended, lupus myocarditis has evidence supporting high-dose corticosteroids combined with azathioprine (or cyclophosphamide in severe cases). The biopsy finding of lymphocytic infiltration with myocyte necrosis in the context of active lupus (elevated anti-dsDNA) confirms immune-mediated injury amenable to immunosuppression. GDMT alone is insufficient for the underlying inflammatory process. Hydroxychloroquine is maintenance therapy, not acute treatment. Plasmapheresis + cyclophosphamide is reserved for refractory or severe organ-threatening lupus, not first-line here.

A 67-year-old man is admitted with NSTEMI and undergoes PCI with drug-eluting stent (DES) to the LAD. He also has atrial fibrillation with CHA₂DS₂-VASc score of 4 and a history of GI bleed 8 months ago. What is the MOST evidence-based antithrombotic regimen at discharge?

Answer: Dual therapy: clopidogrel + apixaban 5 mg BID for 1 month, then apixaban alone

Current evidence (AUGUSTUS, ENTRUST-AF PCI trials) supports 'dual therapy' (P2Y12 inhibitor + DOAC, without aspirin) in patients with AF requiring OAC after PCI, as it reduces bleeding without significantly increasing ischemic events. The AUGUSTUS trial showed apixaban 5 mg BID + P2Y12 was superior to warfarin or aspirin-containing regimens for bleeding. Critically, given his recent GI bleed (8 months ago), minimizing bleeding risk by dropping aspirin early (after 1 month or at discharge) is appropriate. Rivaroxaban 15 mg (reduced dose for AF + PCI, as in ENTRUST) is an alternative, but apixaban-based dual therapy for 1 month transitioning to monotherapy is most aligned with current guidelines for high-bleed-risk patients. Triple therapy is no longer preferred given GI bleed history.

A 72-year-old woman with chronic heart failure with reduced ejection fraction (HFrEF, EF 30%) on optimal GDMT develops symptomatic sinus bradycardia (HR 44 bpm) due to her carvedilol. Her NT-proBNP is 3,800 pg/mL and she has NYHA class III symptoms. Which is the BEST next step?

Answer: Reduce carvedilol dose and add ivabradine if HR remains >70 bpm after optimization

Ivabradine is indicated for HFrEF with EF ≤35%, sinus rhythm, HR ≥70 bpm on maximally tolerated beta-blocker, and NYHA II-IV (SHIFT trial). Here, the patient's HR is 44 bpm — below the threshold for ivabradine initiation (≥70 bpm). The appropriate step is to reduce the carvedilol dose first. If HR stabilizes above 70 bpm at the maximally tolerated beta-blocker dose, then ivabradine can be added. Discontinuing beta-blockers entirely is harmful in HFrEF unless truly intolerable. Switching to metoprolol is a reasonable bradycardia mitigation strategy but doesn't address the full picture. Pacemaker implantation solely to allow continued high-dose beta-blocker is not guideline-supported.

A 55-year-old man with known bicuspid aortic valve and aortic stenosis (valve area 0.7 cm², mean gradient 48 mmHg) is asymptomatic. Echo shows ascending aorta diameter of 4.6 cm. He is an avid marathon runner and asks about continued competitive running. Which statement BEST represents current guidelines?

Answer: He should avoid competitive sports; surveillance imaging every 6 months; refer for surgery given combined AS severity and aortic dilation

Per ACC/AHA guidelines, patients with bicuspid aortic valve and aortic dilation ≥4.5 cm (or ≥4.0 cm with rapid growth or family history of dissection) should avoid competitive sports due to aortic dissection risk. Combined with severe AS (AVA 0.7 cm², mean gradient 48 mmHg), the threshold for surgical intervention is lowered — current guidelines (2021 ACC/AHA Valvular Heart Disease) allow consideration of AVR in asymptomatic severe AS when undergoing other cardiac surgery (e.g., aortic repair), or with very low surgical risk and falling EF or high gradient. With ascending aorta ≥4.5 cm in bicuspid AV disease, surgical repair at the time of AVR is indicated. Referral for surgery is appropriate here on combined indications. Unrestricted marathon running is dangerous given aortic dimensions.

A 61-year-old woman presents with acute chest pain. ECG shows ST depression in V1-V4 and ST elevation in aVR. Troponin is rapidly rising. She is hemodynamically stable. Emergent coronary angiography shows 90% stenosis of the left main coronary artery with TIMI-2 flow and 70% mid-LAD lesion. Her SYNTAX score is 38. Which revascularization strategy is MOST appropriate?

Answer: Emergency CABG with left internal mammary artery to LAD and saphenous vein graft to circumflex

A SYNTAX score ≥33 in the setting of left main disease identifies patients who derive significantly greater survival benefit from CABG versus PCI (SYNTAX trial, NOBLE trial, EXCEL trial long-term data). With a score of 38 and a two-vessel disease pattern (left main + LAD), CABG with LIMA-to-LAD provides a proven long-term survival advantage and lower rates of repeat revascularization. PCI of left main in complex disease (SYNTAX ≥33) is associated with higher MACCE rates. In a hemodynamically stable patient, emergent CABG is feasible and preferred. Deferring the LAD or using medical management alone with rising troponin and high-grade left main disease is inappropriate. FFR assessment should not delay definitive revascularization in this acute high-risk presentation.