PART:3

MCQS OF CARDIOLOGY
WITH BRIEF EXPLAINATION OF ANSWERS
Q.1. You review a 59-year-old man with long-standing hypertension in clinic. He has no
other comorbidities. He complains of some breathlessness, but this does not limit his
physical activity. A transthoracic echocardiogram demonstrates aortic root dilatation and
severe aortic regurgitation.
Which one of the following is not an indication for surgery?

a) NYHA class II breathlessness

b) Aortic root disease with maximal diameter 49 mm

c) Patients undergoing CABG, valve surgery, or surgery of the ascending aorta

d) Asymptomatic with resting LVEF ≤50%

e) Asymptomatic with end-diastolic dimension > 70 mm

ANSWER:
1. B. This man’s echocardiogram shows a dilated aortic root. In this case the likely cause is his long-
standing hypertension. In aortic root disease indication for surgery is based on the maximal aortic
diameter, regardless of the severity of aortic regurgitation. Patients with Marfan’s syndrome should be
offered surgery when their aortic root diameter is ≥45 mm; the figure is ≥50 mm for patients with a
bicuspid aortic valve and ≥55 mm for any other patient (including those with aortic root dilatation
secondary to hypertension, as in this case). Other indications for surgery in severe aortic regurgitation
are:
 Symptomatic patients (NYHA class II, III, or IV dyspnoea or angina)
 Asymptomatic patients with resting LVEF ≤50%
 Patients undergoing CABG, valve surgery, or surgery of the ascending aorta.
 Asymptomatic patients with resting LVEF >50% with severe LV dilatation—LV end-diastolic
dimension >70 mm or LV end-systolic dimension >50 mm (or >25 mm/m2 BSA).
Q2. You are asked to review the echocardiogram of a 74-year-old woman with
a loud pansystolic murmur (z Video 3.).
The following statements are all true, except:

a) The jet of regurgitation is anteriorly directed

b) The regurgitation is likely to be chronic

c) Using PISA to assess the severity of the regurgitant jet is more accurate than
measuring the vena contracta

d) The MV inflow E-wave velocity is .6 m/s; this suggests severe MR

e) Systolic pulmonary vein flow reversal is not a sensitive measure of severe MR

ANSWER:
2. C. The video shows prolapse of the posterior mitral valve leaflet. There is eccentric MR.The vena contracta
(VC) can be measured in both central and eccentric jets to estimate the severity of MR. The VC should ideally
be measured in the apical four-chamber view. PISA is more accurate for central regurgitant jets. Systolic
pulmonary vein flow reversal is specific for severe MR, but is not sensitive. Echocardiographic criteria for the
definition of severe mitral regurgitation are shown in BELOW Table 3.

Valve morphology Flail leaflet/rupture papillary muscle/large coaptation defect

Colour flow regurgitant jet Very large central jet or eccentric jet adhering, swirling, and reaching
the posterior wall of the LA
CW signal of regurgitant jet Dense/triangular
Other qualitative measure Large flow convergence zone
Vena contracta ≥7 mm (>8 mm for biplane)
Upstream vein flow Systolic pulmonary vein flow reversal
MV inflow E-wave dominant ≥.5 m/s Other semi-quantitative measure TVI mitral/TVI aortic >.4 ERO (mm 2 ) ≥40 (primary), ≥20
(secondary) Regurgitant volume (mL/beat) ≥60 (primary), ≥30 (secondary) Enlargement of cardiac chambers LV, LA
3. You are reviewing a 65-year-old farmer in the post-PCI clinic. He had primary angioplasty to his RCA for an inferior sTEMI 3 months previously. He
reports exertional breathlessness but no chest pain. His current medications are aspirin 75 mg od, clopidogrel 75 mg od, ramipril 5 mg bd, bisoprolol
5 mg od, and atorvastatin 80 mg od. On examination his BP is 0/70 mmHg and his heart rate is 60 bpm. You hear a soft pan-systolic murmur at his
apex. His chest is clear and there is no pedal oedema. His ECG shows atrial fibrillation. He manages only 3 minutes on the treadmill with no chest
pain or ECG changes, stopping due to breathlessness. You request an urgent echocardiogram, which demonstrates mild LV systolic dysfunction. The
inferior wall is akinetic, there is some tethering of the posterior mitral valve leaflet, and as a result some mitral regurgitation (ERO = 0.2 cm2).
What is the next appropriate step in his management?

a) Start dabigatran
b) Start eplerenone
c) Urgent repeat coronary angiography
d) Discharge patient with reassurance that he has reasonable LV function and no significant valve
disease
e) Stress echocardiography
ANSWER:
3.E.

This patient has secondary MR. His recent infarct has led to alteration of his LV geometry
(inferior akinesis) resulting in tethering of structurally normal MV leaflets. Ischaemic MR is a
dynamic condition and its severity may vary depending upon changes in loading conditions.
The ESC Guidelines published in 202 propose that, because of their prognostic value,
lower thresholds of severity using quantitative methods should be used in secondary MR. An
ERO ≥20 mm2 or a regurgitant volume ≥30 mL/beat suggests severe MR.
As ischaemic MR is a dynamic condition, stress testing may play a role in its evaluation. An
exercise-induced increase in the ERO of ≥3 mm2 has been shown to be associated with a
large increase in the relative risk of death and hospitalization for cardiac decompensation
(ESC Guidelines 202).
4. An 82-year-old retired solicitor presents to the ED with chest pain radiating to his jaw. He has
hypertension treated with Ramipril 5 mg bd but is otherwise normally fit and well. His admission ECG
shows atrial fibrillation with a ventricular rate of 90 bpm, LVH, and widespread sT segment depression.
His peak troponin is 0 ng/L (normal <30 ng/L). He is started on treatment for an acute coronary
syndrome and listed for an inpatient angiogram. You are asked to perform a bedside echocardiogram as
a systolic murmur is heard on the post-take ward round.
Calculate the aortic valve area (using the continuity equation) from Figures 3.–3.3.

a) A. 0.76 cm2
b) B. 0.80 cm2
c) C. 0.92 cm2
d) D. 1.02 cm2
e) E. 1.08 cm2
Figure 3.
 Fig. 3.3

Figure 3.3
ANSWER:
4. B.

CSAAV = CSALVOT × VTILVOT/VTIAV

CSALVOT = 0.785(2.482)
CSAAV = 4.82 × .6/70.22
CSAAV = 0.798 cm2 = 0.8 cm2