CARDIOLOGY REVISION

SERIES
Part 3 of 4
Dr Shubham Upadhyay

© Medi - Lectures Dr Shubham Upadhyay 1

 DATE CHAPTER NO. TOPIC (TEST & WHATSAPP GROUP DISCUSSION)
12th February 257 Heart Failure: Pathophysiology & Diagnosis
13th February 258 Heart Failure : Management
14th February 259 Cardiomyopathy & Myocarditis
15th February
16th February 261, 262 Aortic Stenosis, Aortic Regurgitation
17th February 263, 264, 265 Mitral Stenosis, Mitral Regurgitation, Mitral Valve Prolapse
18th February 266, 267, 268 Tricuspid Valve Disease, Pulmonic Valve Disease, Multiple &
Mixed Valvular Heart Disease
19th February 269 Congenital Heart Disease in adults
20th February QUICK REVISION OF ABOVE TOPICS
21st February CARDIOLOGY REVISION VIDEO 3 (YOUTUBE)

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Q.1 Orthopnea occurs due to redistribution of fluid from?

A. Coronary circulation
B. Pulmonary circulation
C. Splanchnic circulation
D. Cerebral circulation

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Symptoms of HF
• Symptoms of Congestion
• Shortness of Breath: Exertional Dyspnea-> PND -> Orthopnea-> Dyspnea at rest
• Mechanism: PV conges on, Transuda on into alveoli/inters um-> ↓ lung
compliance, ↑ airway resistance, hypoxemia, VP mismatch

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Symptoms of HF
• Symptoms of Congestion
• Shortness of Breath: Exertional Dyspnea-> PND -> Orthopnea-> Dyspnea at rest
• Mechanism: PV conges on, Transuda on into alveoli/inters um-> ↓ lung
compliance, ↑ airway resistance, hypoxemia, VP mismatch
• Orthopnea
• Recumbant position dyspnea
• Mechanism?
• PND
• Episodes of SOB that awakens patient
• On prolonged recumbency (REM sleep)
• Relief after 30 min upright position. aka Cardiac Asthma

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Symptoms of HF
• Symptoms of Congestion
• Shortness of Breath: Exertional Dyspnea-> PND -> Orthopnea-> Dyspnea at rest
• Mechanism: PV conges on, Transuda on into alveoli/inters um-> ↓ lung
compliance, ↑ airway resistance, hypoxemia, VP mismatch
• Orthopnea
• Recumbant position dyspnea
• Mechanism?
• PND
• Episodes of SOB that awakens patient
• On prolonged recumbency (REM sleep)
• Relief after 30 min upright position. aka Cardiac Asthma
• Right HF: Systemic Venous congestion
• Weight gain, Lower extremity edema
• Abdominal bloating, anorexia, early satiety, RUQ pain
• Anasarca in late stages
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• Symptoms of Reduced Perfusion
• Low output syndrome
• Fatigue & Weakness
• Pathophysiology: ↓ Blood flow to exercising muscles
• Older pa ents: Mental dullness, ↓ affect, confusion

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• Symptoms of Reduced Perfusion
• Low output syndrome
• Fatigue & Weakness
• Pathophysiology: ↓ Blood flow to exercising muscles
• Older pa ents: Mental dullness, ↓ affect, confusion

• Other Symptoms
• Mood disturbances, Poor sleep
• Nocturia
• Oliguria

• Precipitating Factors
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Q.2 Which of the following statement is false regarding HFpEF?

A. Management of patients with HFpEF is focused on improving

symptoms and lifestyle modification
B. ARNI Sacubitril Valsartan is approved for treatment of HFpEF
C. There is clear role of beta blockers in long term mortality reduction
in HFpEF
D. Digoxin may reduce hospitalizations but is not asso. with decreased
mortality in HFpEF

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HFpEF

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HFpEF - Drug Trials
NAME OF TRIAL DRUG RESULT
CHARM Candesartan ↓ hospitaliza on but no ↓ in mortality
I-PRESERVE Irbesartan No ↓ hospitaliza on & mortality
PEP-CHF Perindopril No improvement
DIG Digitalis No ↓ in mortality
SENIORS Nebivolol No significant ↓ in mortality
TOPCAT Spironolactone No ↓ hospitaliza on & mortality
ALDO-DHF Spironolactone Improved Echocardiographic indices of cardiac function but
SPIRRIT-HFpEF Spironolactone Ongoing
FINE-ARTS-HF Finerenone Ongoing
RELAX Sildenafil No ↑ in func onal capacity, QOL, or other parameter
NEAT-HFpEF Isosorbide Mononitrate No ↑ in QOL or exercise capacity
INDIE-HFpEF Inorganic Nitrate No ↑ in func onal capacity, QOL, or other parameter
PARAGON-HF Sacubitril Valsartan 13% ↓ in rate o primary composite endpoint
DELIVER Dapagliflozin Ongoing
EMPEROR-PRESERVED Empagliflozin© Medi - Lectures DrOngoing
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Q.3 Which of the following is most beneficial for symptom reduction in
Typical Acute Decompensated HF with Normotension?

A. Vasodilators
B. Inotropes
C. Diuretics
D. Digoxin

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Acute Decompensated Heart Failure
• General Principles
• ↓ cardiac performance, renal dysfunc on, altera on in vascular compliance
• Management: Volume control, Hemodynamic optimization
1. Identify factors which precipitated decompensation
2. Pharmacotherapy : Hemodynamic op miza on, Relief of conges on,↓ a erload & ↑ vital
organ perfusion
• Parameters associated with worse outcome?

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Acute Decompensated Heart Failure
• General Principles
• ↓ cardiac performance, renal dysfunc on, altera on in vascular compliance
• Management: Volume control, Hemodynamic optimization
1. Identify factors which precipitated decompensation
2. Pharmacotherapy : Hemodynamic op miza on, Relief of conges on,↓ a erload & ↑ vital
organ perfusion
• Parameters associated with worse outcome?
• Volume Management:
• IV Diuretics
• Loop Diuretics : Furosemide, Torsemide, Bumetanide
• Adjuvant Diuretics: Chlorothiazide, Metolazone
• Effective decongestion: Weight change, Improvement in symptoms, Normalization of JVP etc.
• Ultrafiltration

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• Vasoactive Therapy
• IV Nitroglycerin - ↓ Preload
• IV Sodium Nitroprusside - ↓ Preload & A erload
• Nesiritide - Intermediated effects

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• Vasoactive Therapy
• IV Nitroglycerin - ↓ Preload
• IV Sodium Nitroprusside - ↓ Preload & A erload
• Nesiritide - Intermediated effects
• Inotropic Therapy
• Sympathomimetic Amines (Dopamine, Dobutamine)
• PDE 3 inhibitor (Milrinone)
• Greater ↓ in SVR & pulm. vascular resistance
• ↑ risk of hypotension
• Can be used in beta blocker therapy
• ↑ CO, reduces SVR, improves perfusion & relieves conges on
• Used as Bridge therapy : long term is avoided

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Q.4 Soluble Guanyl cyclase stimulator under study for HFrEF?

A. Vericiguat
B. Omecamtiv mecarbil
C. Moxonidine
D. Xamoterol

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• SGLT 2 Inhibition
• ↓ in worsening of HF or death from CV causes in both diabe cs & non DM

• Soluble guanyl Cyclase Stimulation

• NO signalling pathway -> ↑cGMP forma on -> Vasodila on
• Vericiguat : Novel oral sGC stimulator
• VICTORIA trial

• Myosin Activation
• Prolong ventricular systole without ↑ myocardial contrac lity
• Omecamtic mecarbil : Selective myosin activator
• Oral drug
• COSMIC-HF trial
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Q.5 All are true except Restrictive CMP except?

A. EF is usually in between that seen in DCMP and HCMP

B. Associated with increased atrial size
C. Left HF signs such as pulmonary edema dominates
D. None of the above

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Cardiomyopathies

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Q.6 All are true regarding Viral myocarditis except?

A. Unchecked secondary adaptive immune response can perpetuate

secondary myocardial damage
B. "Possible acute myocarditis" is defined when symptoms of HF are
present without ECG , Echo and cardiac biomarkers positivity
C. MC viruses include Coxsackie, Enterovirus
D. HAART used to treat HIV associated myocarditis is itself associated
with cardiomyopathy

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Major Causes of DCMP

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Myocarditis
• Inflammation of Myocardium

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Infective Myocarditis
• Common with Viruses & Trypanosoma cruzi
• Viral Myocarditis
• Pathogenesis : 3 phases
1. Direct Viral invasion phase
2. Innate immune response
3. Adaptive Immune response
• Clinical Presentation
• Acute Viral Myocarditis
• Chronic Viral Myoarditis
• Lab Evaluation: ECG, Echo, Troponin & CK, MRI, Endomyocardial Biopsy?
• Diagnosis:
• Possible subclinical acute mycarditis
• Probable acute myocarditis
• Definite myocarditis
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• Viral Myocarditis
• Etiology
• RNA viruses: Enterovirus, Coxsackie virus, Echovirus, Poliovirus, Influenza
• DNA virus: Adeno, Vaccinia, VZV, CMV, EBV, HHV 6)
• HIV : HAART has ↓ the incidence
• Hepatitis C
• Treatment
• No specific therapy : Supportive treatment
• Neither antiviral, nor anti inflammatory drugs are recommneded

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• Viral Myocarditis
• Etiology
• RNA viruses: Enterovirus, Coxsackie virus, Echovirus, Poliovirus, Influenza
• DNA virus: Adeno, Vaccinia, VZV, CMV, EBV, HHV 6)
• HIV : HAART has ↓ the incidence
• Hepatitis C
• Treatment
• No specific therapy : Supportive treatment
• Neither antiviral, nor anti inflammatory drugs are recommneded
• Parasitic Myocarditis
• Chagas’ Disease
• Mc infective cause of cardiomyopathy
• Conduction abormalities, Tachyarrythmias
• Treatment: Benznidazole, Nifurtimox
• African trypanosomiasis
• Toxoplasmosis
• Thichinellosis
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• Bacterial Myocarditis
• Diphtheria
• MC bacterial cause
• Dipherial toxin
• Treatment: Antitoxin > Antibiotic
• Clostridium: Toxin
• Beta hemolytic streptococci
• Tuberculosis
• Whipple’s Disease
• Trophyrema whipplei
• Pericarditis, Coronary arteritis, Valvular lesions, heart failure
• Treatment: Multidrug ATT regimens
• Others
• Brucellosis, Legionella, Meningococcus, Mycoplasma, Psittacosis, Salmonella
• Tick Borne Infections
• Lyme disease : Borrelia burgdorferi
• Rocky mountain spotted fever, Q fever,
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Non Infective Myocarditis
• Granulomatous Myocarditis
• Sarcoidosis
• can lead to Rapid onset HF, V Tach, Conduction blocks, chest pain
• Treatment: High dose GC + Methotrexate
• Giant Cell Myocarditis
• 10-20% cases of myocarditis
• Rapidly progressive HF, Tachyarrhythmias
• Associated conditions?
• Eosinophillic Myocarditis
• Hypereosinophillic syndrome
• Infiltration with Eosinophils
• MC: Drug induced
• Polymyosistis & Dermatomyositis
• Collagen Vascular Diseases
• Check Point Inhibitors © Medi - Lectures Dr Shubham Upadhyay 35
Q.7 Multidrug ATT regimen are effective in the treatment of
myocarditis due to?

A. Brucellosis
B. Whipple's Disease
C. Clostridial infections
D. Psittacosis

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Q.8 Which of the following is not a characteristic symptom of AS?

A. Exertional Dyspnea
B. Angina
C. Syncope
D. Palpitation

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Aortic Stenosis
• MC vavular heart disease among elderly. M>F
• Causes:
• Congenital : Bicuspid, Unicuspid
• Acquired : Degenerative, Rheumatic fever, Radiation
• Severe AS?
• Symptoms: Angina, Syncope, Dyspnea. Late --> LV failure
• Signs:
• Hypertension, Pulsus parvus et tardus
• Auscultation : S1, S2, S3, S4
• Murmur : Ejection Systolic Murmur. Gallavardin effect?
• Treatment
• Medical : Betablockers, ACE -, NTG, Statins
• Aortic valve replacement ©: SAVR, TAVI
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Aortic Regurgitation
• Etiology: Valve Disease, Root disease or Combination
• Acute vs Chronic AR
• Physical findings
• Jarring of body, Bobbing of head
• Arteral pulse: Water hammer, Quinke’s, Traube’s sign, Duroziez’s sign
• Auscultation
• A2: Absent
• Murmurs:
• Early diastolic
• Ejection Systolic
• Mid - Late Diastolic

• Management
• Acute AR
• Chronic AR: Indications of Surgery?
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Q.9 Which of the following murmur is heard in chronic AR?

A. Decrescendo diastolic murmur

B. Mid systolic ejection murmur
C. Mid to late diastolic murmur
D. All of the above

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Q.10 All are true regarding MS except?

A. In very severe MS, CO is subnormal at rest and fail to rise during

activity
B. LV diastolic pressure and ejection fraction decreases in MS
C. Latent perod from initial rheumatic carditis to development of MS
symptoms is 20 yrs
D. In late MS, Vital capacity, total lung capacity decreases

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Mitral Stenosis
• MCC - Rheumatic Fever (Latent period ~20 yrs)
• Symptoms: Exertional dyspnea, cough -> Resting dyspnea, Orthopnea,
PND, Hemoptysis
• Signs
• JVP
• Cardiac Auscultation: S1 loud, S2 loud, Opening Snap, Diastolic murmur
• Severity
• Severe MS : <1.5 cm2
• Very Severe MS : <1 cm2
• Pulmonary Changes?
• Pulmonary HTN
• Fibrous thckening of alveoli
• VC, TLC, Breathing Capacity & O2 uptake ↓
• LV Changes? © Medi - Lectures Dr Shubham Upadhyay 42
Mitral Regurgitation
• Etiology
• Acute: IE, Post MI, Chordal rupture, Blunt trauma
• Chronic :
• Primary (Leaflets, Chordae) : Myxomatous, RHD, IE
• Secondary (Annulus, Papillary ms, Myocardium) : Ischemic CMP, DCMP, HOCM
• Mitral Annular calcification
• Symptoms: Usually asymptomatic
• Fatigue, Exertional Dyspnea, orthopnea
• Late stages : Right HF
• Signs :
• Auscultation: S1 absent or soft, S2 wide split, Murmur?
• Treatment
• Medical: AF (Anticoagulation, Antiarrhythmics), GDMT
• Surgical: Transcatheter MV repair/Replacement
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Q.11 Chronic secondary MR occurs due to involvement of Mitral
leaflets & chordae tendinae.

A. True
B. False

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Q.12 Which view in echocardiography is best to diagnose Mitral Valve
prolapse?

A. Parasternal long axis view

B. Parasternal short axis view
C. Four chamber view
D. All of the above

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Mitral Valve Prolapse
• Barlow’s Syndrome, Systolic Click murmur syndrome
• F>M, 15-30 yrs, Autosomal Dominant
• ↓ produc on of type 3 collagen
• Causes?
• Posterior leaflet > Anterior leaflet
• Clinical features
• Palpitations, chest pain, Syncope
• Mid-late Non ejection systolic click
• Murmur?
• Diagnosis : 2D Echo
• Treatment
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Q.13 All are true regarding TR except?

A. >85% of all cases of TR are functional & MC seen in association with

PAH
B. JVP in TR characteristiclly has prominent c-v waves with prominent
y descent
C. Severe TR is accompanied by hepatic vein systolic flow reversal
D. Carcinoid is the MC secondary cause of TR

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Tricuspid Regurgitation
• >85% cases : Secondary (functional)
• Secondary TR is MC associated with severe PAH
• Symptoms :
• Related to left valvular lesions
• Fatigue, Exertional dyspnea
• Physical findings
• JVP : Prominent c-v waves, Rapid y descent
• Murmur : Holosystolic, Carvallo’s sign
• Severe TR : Hepatic vein systolic flow reversal
• Treatment
• Medical: Diuretics, Aldosterone antagonist
• Tricuspid valve surgery
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Q.14 All of the following CHD lead to dilatation of Right heart except?

A. VSD
B. ASD
C. Ebstein anomaly
D. PAPVR

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Intracardiac shunts or intravascular passages that occur below the
level of the tricuspid valve result in left heart dilation.
The two major types of congenital shunts that result in left heart
dilation are a ventricular septal defect(VSD) and patent ductus
arteriosus (PDA)

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Q.15 All of the following procedures are used for repair of TGA except?

A. Atrial Switch
B. Arterial Switch
C. Fontan procedure
D. Rastelli procedure

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Complex ACHD
• Tetralogy of Fallot
• Transposition of Great Arteries
• Coarctation of Aorta
• Single Ventricle Physiology

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 Transposition of Great Arteries
• Great arteries arising from opposite side of ventricular septum
• Aorta arises from RV, PA from LV
• Types
• D Loop TGA : More common
• AV concordance, Ventriculoarterial discordance
• Intense cyanosis shortly after birth
• Surgical repair
• Atrial Switch : Systemic RV
• Rastelli Procedure : RV to PA conduit, routing LV to aorta through VSD
• Arterial Switch
• L loop TGA : Congenitally corrected TGA
• Both AV discordance, Ventriculoarterial discordance

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Single Ventricle Physiology
• Causes:
• Tricuspid Atresia
• Double inlet LV
• Hypoplastic left heart syndrome
• Treatment : Fontan procedure
• Single Ventricle pumps ---> Aorta
• Passive flow of venous return --> Pulmonary Artery
• Complications in later life:
• Atrial arrhythmias
• Heart failure
• Renal & Hepatic dysfunction
• Thromboembolism
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