ITE Cardiovascular Disease 3 — Questions and Answers
Question 1: A 45-year-old woman with no cardiac history presents with sharp pleuritic chest pain and a pericardial friction rub 2 weeks after a viral URI. ECG shows diffuse ST elevation with PR depression. What is the first-line treatment?
- Anticoagulation with heparin
- NSAIDs plus colchicine (Correct answer)
- Prednisone 1 mg/kg/day
- Pericardiocentesis
Correct answer: NSAIDs plus colchicine
Acute viral pericarditis is treated with NSAIDs plus colchicine, which reduces recurrence; steroids are reserved for refractory cases.
Question 2: Which drug interaction is most clinically significant in a patient taking warfarin who is newly prescribed amiodarone?
- Amiodarone decreases warfarin absorption
- Amiodarone inhibits CYP2C9, increasing warfarin effect (Correct answer)
- Amiodarone increases renal warfarin clearance
- Amiodarone displaces warfarin from albumin only
Correct answer: Amiodarone inhibits CYP2C9, increasing warfarin effect
Amiodarone inhibits CYP2C9 (and CYP3A4), significantly reducing warfarin metabolism and increasing anticoagulant effect, requiring close INR monitoring and dose reduction.
Question 3: A 55-year-old man with STEMI is treated with primary PCI. Two days later he develops new hypotension, elevated JVP, and a new holosystolic murmur at the left lower sternal border. What is the most likely diagnosis?
- Acute mitral regurgitation due to papillary muscle rupture
- Ventricular septal defect (VSD) (Correct answer)
- Free wall rupture with tamponade
- Dressler syndrome
Correct answer: Ventricular septal defect (VSD)
Post-MI VSD typically occurs 2–5 days after infarction, presenting with a new harsh holosystolic murmur, right heart failure signs, and hemodynamic compromise.
Question 4: A 68-year-old man with stable angina has a 70% stenosis of the left anterior descending artery on coronary angiography. His symptoms are well-controlled on medical therapy. What is the preferred management?
- Immediate PCI to prevent MI
- Continue optimal medical therapy (Correct answer)
- CABG to improve survival
- Implantable cardioverter-defibrillator
Correct answer: Continue optimal medical therapy
In stable ischemic heart disease, PCI does not reduce MI or mortality compared to optimal medical therapy (COURAGE trial), making medical management preferred for stable symptoms.
Question 5: Which physical examination finding is most specific for cardiac tamponade?
- Elevated JVP with Kussmaul's sign
- Pulsus paradoxus >10 mmHg (Correct answer)
- Distant heart sounds
- Pericardial friction rub
Correct answer: Pulsus paradoxus >10 mmHg
Pulsus paradoxus (>10 mmHg drop in systolic BP during inspiration) is the most specific physical finding for cardiac tamponade.
Question 6: A 72-year-old woman has a resting heart rate of 38 bpm and ECG showing P waves with no relationship to QRS complexes, which are narrow at 60 bpm. She is asymptomatic. What is the most appropriate treatment?
- IV atropine immediately
- Permanent pacemaker implantation (Correct answer)
- Observation with Holter monitoring
- Temporary transvenous pacing only
Correct answer: Permanent pacemaker implantation
Complete (third-degree) AV block with an escape rhythm, even if asymptomatic, carries risk of syncope and sudden death and is a Class I indication for permanent pacemaker.
Question 7: A patient with hypertrophic obstructive cardiomyopathy (HOCM) develops worsening symptoms. Which intervention is contraindicated?
- Beta-blockers
- Disopyramide
- Surgical septal myectomy
- Nitrates for angina relief (Correct answer)
Correct answer: Nitrates for angina relief
Nitrates reduce preload and systemic vascular resistance, worsening the dynamic outflow tract obstruction in HOCM and are contraindicated.
ITE Cardiovascular Disease 3
A 45-year-old woman with no cardiac history presents with sharp pleuritic chest pain and a pericardial friction rub 2 weeks after a viral URI.
ECG shows diffuse ST elevation with PR depression.
What is the first-line treatment?