Sample Questions

Unit C - Pathology

Taken directly from Todd's CV Review books, 7th Edition

Unit C, Chapter 1 – Acquired Valvular Disease
Question #752

Identify 3 words describing a "leaky" heart valve pathology as shown at #2. (Select 3)
a. Obstructive
b. Insufficient
c. Restrictive
d. Stenotic
e. Regurgitant
f. Incompetent

Check Your Answer

ANSWERS: b, e, f.
Leaky valves do not close competently. There is leakage of blood back into the proximal chamber. They may open widely during ejection, but their valve cusps don't coapt (close) properly. This diagram shows four different pathologies of the aortic valve. However, the AV valve pathologies are similarly named.
VALVE PATHOLOGIES SHOWN ARE:
1. A prolapsing valve does not hold its position when closed. High distal pressure and an enlarged valve cause it to balloon back into the proximal chamber. The AV valves are most prone to prolapse when chordae and papillary muscles are damaged. Occasionally, a prolapsing valve may balloon or buckle so much that it leaks.
2. A regurgitating valve leaks. It is not "competent" to do its job of allowing flow in only one direction - it "insufficiently" coapts or closes. Leaky heart valves cause volume overload and dilatation of the proximal chamber. They also cause loss of pressure and cardiac output to the distal chamber.
3. A stenosis is a blockage or narrowing that obstructs blood flow. Stenosis restricts blood flow and pinches off the forward cardiac output. (In coronary arteries we sometimes call these obstructions "lesions.") Significant stenosis always causes a pressure gradient due to its high resistance to flow. It results in pressure overload and eventual hypertrophy of the proximal chamber. These two types of valve problems are distinctly different, with completely different physiological consequences. However, calcified valves often exhibit both regurgitation and stenosis. Here, there is a regurgitant jet and a stenotic gradient.
4. Restrictive defects form a barrier around the ventricle that limits diastolic filling and venous return. Restriction does not affect the valve leaflets. It is a "diastolic disorder" e.g., in constrictive pericarditis a tight pericardium limits (constricts) ventricular expansion in diastole. The tight pericardium allows a small initial rapid fill, then cannot expand further. Since the venous return is so restricted, the stroke volume and CO are reduced. Restriction is listed in this chapter only because it has distinct hemodynamic consequences.
Synonyms for Heart Valve Pathologies

Unit C, Chapter 2 – Pericardial and Myocardial
Question #844

These are diagrams of hearts showing types of RESTRICTIVE or CONSTRICTIVE CARDIAC pathology. Identify the pathology seen at #3 on the diagram.
a. Cardiac tamponade (effusive)
b. Cardiac tamponade (hemorrhagic)
c. Constrictive pericarditis
d. Restrictive cardiomyopathy

Check Your Answer

ANSWER: c. Constrictive pericarditis is shown in diagram #3.
BE ABLE TO CORRECTLY MATCH ALL ANSWERS BELOW.
1. CARDIAC TAMPONADE - EFFUSIVE: When irritated the pericardium secretes a straw-colored serous fluid into the pericardial cavity, rather like a burn develops a boil. Irritants include neoplasm (cancer), radiation therapy, uremia, or infection. When this begins to constrict filling of the heart it is termed effusive tamponade.
2. CARDIAC TAMPONADE - HEMORRHAGIC: The pericardium is filled with blood and clots. But once blood in the pericardial space often does not clot because of the nature of the pericardial fluid (sero-sanguinous fluid). Still, clots may develop. Blood may enter the pericardium through a ruptured transmural myocardial infarction (shown). Or it may enter because of a catheter puncture through the myocardium. Pericardial-centesis can be lifesaving in tamponade. The heart cannot fill properly because the effusion compresses it. If it cannot fill – it has nothing to pump.
3. CONSTRICTIVE PERICARDITIS: The pericardium becomes stiffened and encases the heart in a shell. The surgeons compare doing a CP pericardiectomy to peeling off an "orange rind." This rind limits the diastolic filling of the heart and elevates the filling pressures.
4. RESTRICTIVE CARDIOMYOPATHY: This heart is so stiff that it impedes diastolic filling. Hemodynamics of CP and RC are similar and often confused with constrictive pericarditis. Biopsy may be needed to differentiate the two pathologies.
See: Braunwald, chapter on "Pericardial Diseases"

Unit C, Chapter 3 – Coronary Artery Disease and M.I.
Question #881

A patient has signs and symptoms of myocardial infarction. Myocardium may be preserved from necrosis if _____ is administered within _____ hours of the symptom onset.
a. A heparin drip, 3-4 hours
b. A heparin drip, 24-48 hours
c. A thrombolytic drug, 3-4 hours
d. A thrombolytic drug, 24-48 hours

Check Your Answer

Time From Symptom Onset to Reperfusion Therapy ANSWER: c. Thrombolytic drug, 3-4 hours.
Thrombolytic drugs can dissolve clots that cause the infarction. The sooner blood flow is reestablished, the better. The window of opportunity to salvage myocardium is generally considered to be within the first 4-6 hours after the initial symptoms of MI. Time is critical. It has led to rapid-response STEMI cath teams. Thrombolysis is effective at restoring blood flow but cannot revive dead myocardial cells. Acute PCI for MI may have important advantages over thrombolytic drugs, but this requires urgent coronary arteriography, which may not be available in outlying areas of the country. This diagram shows the window for myocardial salvage and successful intervention.
See: Braunwald, chapter on "MI"

Unit C, Chapter 4 – Heart Failure and Shock
Question #958

Heart failure is an abnormal state of cardiac function which fails to meet the needs of metabolizing tissues or can only meet them with:
a. Increased coronary flow
b. Increased cholinergic stimulation
c. Increased blood pressure
d. Increased venous pressure

Check Your Answer

ANSWER: d. Increased venous pressure.
Heart failure is a pathologic state where poor cardiac function fails to pump enough blood to meet the requirements of metabolizing tissues, or it can only do so with an elevated filling pressure.

CHF is caused by either a weakening of myocardial contraction (as from acute MI) or an inability of the heart to meet some acute volume or pressure load (such as acute AI or AS); or the diastolic function is impaired (as in pericardial tamponade). CHF has many causes. But THE COMMON DENOMINATOR IS COMPENSATORY ELEVATION OF THE VENOUS PRESSURES. This means increased CVP in right heart failure, and/or increased wedge, PAedp, and LVEDP in left heart failure.

See: Braunwald, chapter on "Clinical Aspect of Heart Failure"

Unit C, Chapter 5 – Congenital Heart Disease
Question #1021

Normal anatomic positioning with the LA and LV apex on the patient's left side is termed:
a. Situs inversus, levocardia
b. Situs inversus, dextrocardia
c. Situs solitus, levocardia
b. Situs solitus, dextrocardia

Check Your Answer

ANSWER: c. Situs solitus, levocardia.
Situs solitus is Latin for normal visceral position (e.g. liver on the right side.) This means the venous blood enters the RA on the right side. When the viscera are mirror image reversed it is termed situs inversus. Being inverted the RA and liver are on the left side. Levocardia refers to a left sided LV apex ("levo" means "left"). When the LV apex points to the patient’s right side it is termed "dextrocardia."

See: Braunwald, chapter on "Congenital Heart Disease"

Unit C, Chapter 6 – Vascular Disease
Question #1044

The abbreviation used in the vascular procedure labeled at #2 (Compression of subclavian artery or nerves) is:
a. TIA
b. CVA
c. TOS
d. EVAR
e. DVT
f. AVF (AVM)
g. AAA
h. FMD
I. RVH
j. Bruit

Check Your Answer

ANSWER: c. TOS
TOS = Thoracic Outlet Syndrome = COMPRESSION OF THE SUBCLAVIAN ARTERY OR NERVES as they exit the thorax, resulting in arm numbness and pain. BE ABLE TO CORRECTLY MATCH ALL ANSWERS.

VASCULAR ABBREVIATIONS = DEFINITION
1. AAA = Abdominal Aortic Aneurysm = BULGING AORTA in the abdomen
2. TOS = Thoracic Outlet Syndrome = COMPRESSION OF SUBCLAVIAN ARTERY OR NERVES as they exit the thorax, resulting in arm numbness and pain
3. FMD = Fibro-Muscular Dysplasia = HYPERPLASTIC WEB OR FIBROSING LESIONS IN ARTERY - usually increased medial fibrous tissue with mural aneurysms (ectatic).
4. RVH = Reno-Vascular Hypertension = INCREASED blood pressure (hypertension) DUE TO RENAL ARTERY STENOSIS or other obstruction to renal blood flow that activates the reninangiotensin vasoconstrictor system
5. TIA = Transient Ischemic Attack = SMALL STROKE (Temporary interference with the brain’s blood supply) - resolves in 24 hours
6. CVA = Cerebral Vascular Accident = STROKE = Pathologic ischemia or hemorrhage within the brain (apoplexy) - effects last over 24 hours
7. DVT = Deep Vein Thrombosis = CLOTTING of deep LEG VEINS (in 25% DVT leads to PE/Pulmonary Embolism.)
8. EVAR = Endovascular Aortic Repair - usually of aortic aneurysms with stents or stentgrafts
9. AVF/AVM = Arterio Venous Fistula or Malformation = SHUNT BETWEEN ARTERY AND VEIN (Usually for renal DIALYSIS)
10. BRUIT (not an abbreviation) = Stenotic arterial (or venous) murmur = sound of blood rushing through a constricted vessel

See: Kandarpa, appendix of “Abbreviations”