Sample Questions
Unit F - Interventions
Taken directly from Todd's CV Review books, 7th Edition
Unit F, Chapter 1 – Percutaneous Coronary Interventions
Question #1
Identify 4 indications for the most successful stent placement. (Select 4 below.) a. Discrete de novo lesions
b. Bifurcation lesions
c. Medial dissection
d. Elastic recoil after POBA
e. Total occlusion
Check Your Answer
Bifurcation lesions are NOT a major indication for stent placement. Bifurcation lesion stents are more difficult to place successfully, have more complications, and have poorer outcomes when compared to POBA. Although, there are several techniques for stenting bifurcation lesions, by placing 2 stents or creating holes in the stent, they are all difficult. "De novo" means a virgin lesion that has never been treated by an invasive procedure. Grossman says about bifurcation stenting: "None of these [bifurcation stenting] techniques is completely reliable, and their complexity and high restenosis rates lead us to favor debulking approaches for most such lesions."
See: Grossman, chapter on "Coronary Stenting"
Unit F, Chapter 2 – PCI Equipment
Question #98
PCI balloon inflation pressures are usually measured in:
a. Torr
b. PSI
c. mmHg
d. Atmospheres
ANSWER: d. Atmospheres.One atmosphere gauge pressure is 15 PSI or 760 mmHg or Torr. Watson says: "Inflation pressures are quoted in atmospheres or bars...." The monitor tech records the inflation pressure and how long the balloon was left inflated.
See: Watson, Invasive Cardiology, chapter on “PTCA”
Unit F, Chapter 3 – Adjunct Percutaneous Devices
Question #164
What are the advantages that diamond burr atherectomy has over balloon angioplasty (POBA)? (Select 3 below.)
a. It produces less vessel dissection
b. It produces less embolization of debris
c. It enlarges the lumen without vessel remodeling
d. It minimizes stretch & elastic recoil in treated vessels
e. It releases antiproliferative drugs to reduce intimal hyperplasia
It produces much more debris than POBA, because the diamond burr pulverizes calcified plaque into micro-particles which are washed away by the blood stream. Of course, that is the good purpose of rotational atherectomy (RA), to remove the hard calcified plaque. But that is also why the Rotablator is prone to no-reflow - debris embolization occluding distal capillary beds. IC adenosine and other dilators help this debris pass. The atherectomy enlarges the lumen without vessel dissection or dilation, which is common in POBA. The burr has no drug effects.
Unit F, Chapter 4 – Advanced Cardiac Life Support I
Question #264
What is the single most important modifiable risk factor for CAD?
a. Cigarette smoking
b. Chronic hypertension
c. High blood cholesterol
d. Obesity of the abdomen
Braunwald says, “Other than advanced age, smoking is the single most important risk factor for coronary artery disease. Cigarette consumption is the leading preventable cause of death in the United States.... Beyond acute unfavorable effects on blood pressure and sympathetic tone, and a reduction in myocardial oxygen supply, smoking affects atherothrombosis by several other mechanisms.... Cessation of cigarette consumption overwhelmingly remains the single most important intervention in preventive cardiology.”
See: Braunwald, chapter on “Risk Factors”
Unit F, Chapter 5 – Advanced Cardiac Life Support II
Question #363
Match each acute coronary syndrome patient to his/her optimal therapy - as recommended in the ACLS guidelines. (All patients have received MONA, IV heparin, and beta blockers.)
a. A 78-year-old man with 3 mm ST-segment elevation and signs of cardiogenic shock presenting to a large hospital within 12 hours of symptom onset. Continuing pain.
b. A 65-year-old man with 2 mm ST-segment elevation MI, presenting within 2 hours of onset of symptoms at an off-site ER. Continuing pain.
c. A 80-year-old lady with 2 mm ST-segment depression whose pain is relieved with GP IIb/IIIa inhibitors
1. Fibrinolytic if d-n time is < 30 min. = b. 65-year-old man with 2 mm ST-segment elevation MI, presenting within 2 hours of onset of symptoms off-site. Continuing pain. This patient is a better candidate for fibrinolytic therapy, because, although PCI is recommended, the PCI facility is not readily available and fibrinolysis is an option if the 90-minute door to balloon cannot be met. In many regional systems, a combination of lower dose thrombolytics and transfer to a PCI capable facility is employed. Door to needle time < 30 min.
2. Catheterization and PCI d-b time is < 90 min. = a. 78-year-old man with 3 mm ST-segment elevation and signs of cardiogenic shock presenting within 12 hours of symptom onset. Continuing pain. This patient will do best with percutaneous coronary intervention (PCI). He does not present within the optimum 12-hour window for fibrinolytic drugs. Also, the presence of cardiogenic shock indicates an urgent need to restore perfusion to the myocardium quickly as PCI can do. ACLS manual states: "For patients more than 75 years of age, fibrinolytic therapy drops to a Class IIa intervention (from recommended to acceptable). The risks of complications of fibrinolytic therapy (primary intracranial hemorrhage), increases in this age group, but so does the risk and mortality rate of AMI... PCI may be a better alterative in some patients at increased risk for hemorrhage.)"
3. Admit to CCU for monitoring (low risk ACS) = c. 80-year-old lady with 2 mm ST-segment depression whose pain is relived with GP IIb/IIIa inhibitors. This patient appears to stabilize with GP IIb/IIIa platelet antagonists and heparin. Continue to monitor her for unstable angina. If ST depression returns with signs of ischemia send to cath lab to evaluate for PCI. However, if the patient can be admitted to the cath lab and assured a less than 90 min “door-to-balloon” time, and skilled and experienced operators are present (>75 interventions per year) PCI is recommended as a first option before thrombolysis therapy.
See: AHA, ACLS Provider Manual: https://www.acls.net/images/algo-acs.pdf
Unit F, Chapter 6 – Cardiac Medications I
Question #421
Match the cardiovascular drugs listed below with the classes in the box.
a. Lidocaine, Procainamide
b. Verapamil, Adenosine
c. Digitalis, Dobutamine
d. Isoproterenol, Atropine
e. Norepinephrine, Dopamine (high dose)
BE ABLE TO MATCH ALL ANSWERS.
1. Pressor = e. Norepinephrine, Dopamine (high dose). Vasopressors vasoconstrict peripheral arterioles raising the BP.
2. Chronotropic = d. Isoproterenol, Atropine. Chorono- means rate. These drugs primarily increase heart rate. Isoproterenol (Isuprel) stimulates beta-1 receptors. Atropine blocks vagal bradycardia to speed the heart rate.
3. Inotropic = c. Digitalis, Dobutamine. Inotropism increases inherent contractility of myocardial fibers.
4. Ventricular Antiarrhythmic = a. Lidocaine, Procainamide. Decrease automaticity in SA node and conduction velocity in reentry loops.
5. Supra-ventricular Antiarrhythmic = b. Verapamil, Adenosine. Verapamil blocks slow inward movement of Ca into the cell. (Ca channel blocker). Adenosine slows AV conduction and interrupts AV nodal reentry pathways.
See: ACLS Manual
Unit F, Chapter 7 – Cardiac Medications II
Question #507
A class of drug specifically used to block the "Renin-Angiotensin-Aldosterone" system in hypertension is:
a. Beta blocker
b. Ca channel blocker
c. ACE inhibitor
d. Digitalis
a. NO: BETA BLOCKERS (e.g., Inderol) block the beta adrenergic receptors.
b. NO: CA CHANNEL BLOCKERS (e.g., Nifedipine) block the Ca+ fast channels. Slow HR and vasodilate smooth muscle.
c. YES: ACE INHIBITORS (e.g., Captopril) block conversion of angiotensin I to angiotensin II. These reduce renin, angiotensin II, and aldosterone blood levels and thus the Na+ retention and vasoconstriction problems.
d. NO: DIGITALIS, cardiotonic or inotropic drug.
See: Braunwald, chapter on "The Management of Heart Failure"
Unit F, Chapter 8 – Pacemakers and Heart Rhythm Devices
Question #595
Identify the left heart and/or aortic angiographic flood catheter bend labeled #1 in the diagram.
a. Hypersensitive carotid sinus syndrome
b. Sick sinus syndrome
c. Complete heart block
d. Sinus rhythm
Moses says: "The sick sinus syndrome is the condition most commonly treated by pacemaker placements. This disorder includes a variety of cardiac arrhythmias, all characterized by SA arrest or SA exit block. The result of both is sinus bradycardia. The junctional escape mechanism may be inappropriately slow in patients with sick sinus syndrome. Patients with SA node dysfunction often have alternating supraventricular tachycardias and bradycardias. This seemingly paradoxical juxtaposition of rapid and slow heart rhythms has resulted in the term tachy-brady syndrome."
See: Moses, chapter on "Indication for Pacing"
Unit F, Chapter 9 – Intra-Aortic Balloon Pump
Question #691
During intra-aortic balloon augmentation, the relative heights of systole and diastole are important. Augmented Diastolic PTI (#3) is the area under the arterial pressure curve in diastole when the balloon is inflated. Since diastolic area #3 is larger than diastolic area #2, it shows that balloon inflation:
a. Increases preload and afterload
b. Reduces LV- AO pressure gradient
c. Reduces O2 demand and cardiac work
d. Increases O2 supply and coronary flow
The augmented (higher) diastolic coronary pressure means that more blood flows into the coronary arteries. This increases the O2 supplied to the myocardium and reduces ischemia. O2 demands of the body must be matched by a corresponding O2 supply (increased CO and coronary flow), otherwise the patient gets coronary ischemia and angina. Pressure Time Index (PTI) and Tension Time Index (TTI) are the areas under the pressure curves. Datascope has excellent counterpulsation online training programs, both accredited and nonaccredited.
Unit F, Chapter 10 – Impella and Other LVADs
Question #776
Which ventricular assist device consists of a single catheter that can be inserted percutaneously across the aortic valve and is used to unload the LV?
a. Intra-aortic counterpulsation
b. Impella
c. HeartMate II connected to LV apex
d. Tandem Heart via transseptal catheter
The Impella helical pump unloads the LV by pulling blood out of it and pumping it into the aorta. Impella 2.5 can pump up to 2.5 L/min and is inserted percutaneously in the FA via a 13 Fr sheath. tVAD stands for transvalvular ventricular assist device, because it is placed across the aortic valve.
Kern says, “...recently, the Impella family of devices (ABIOMED, Inc., Danvers, MA) has become the next generation of circulatory support tools. This device can be readily placed in the cardiac catheterization laboratory via arterial access and provides direct unloading of the left ventricle with an array of support levels. An Impella 5.0 catheter provides up to 5.0 L/min of support. This catheter requires arterial cutdown, placement of a 21-F sheath, and therefore possible surgical assistance.”
“The Impella catheter, considered a transvalvular ventricular assist device (tVAD), pulls blood from the LV chamber and pumps the blood into the aorta. The major benefits to this device involve direct unloading of the left ventricle, decreased filling pressures / volumes, and increased cardiac output. Several studies have shown improved hemodynamics with the Impella catheter when compared with the IABP. The major contraindications to this device are LV thrombus, severe aortic valve stenosis, mechanical aortic valve, and peripheral arterial disease.”
See: Kern, chapter on “High Risk Cardiac Catheterization”
Unit F, Chapter 11 – Valvular and Coronary Interventions
Question #816
Match the type of cardiac surgery with its description below.
a. Open chest surgery with heart lung bypass and cardioplegia
b. Open chest surgery with no heart lung bypass (requires stabilizers)
c. A form of OPCAB endoscopic surgery with surgeon at bedside manipulating instruments through keyhole ports between ribs
d. Endoscopic coronary bypass surgery through keyhole ports with surgeon manipulating instruments from a remote console
1. Robotic = d. Endoscopic coronary bypass surgery through keyhole ports with surgeon manipulating instruments from a remote console.
2. OPCAB = b. Open chest surgery with no heart lung bypass (requires stabilizers).
3. MIDCAB = c. A form of OPCAB endoscopic surgery with surgeon at bedside manipulating instruments through keyhole ports between ribs.
4. Open Heart = a. Open chest surgery with heart lung bypass and cardioplegia.
Unit F, Chapter 12 – Vascular and Other Interventions
Question #916
At the end radial artery PCI the physician has applied a syringe inflatable pneumatic cuff. You are asked to provide hemostasis. Radial artery access closure is best monitored with patent hemostasis using:
a. Visual inspection for hand color
b. A vascular closure device
c. A blood pressure cuff
d. A pulse oximeter
Watson & Gorski say, “Regardless of the mechanism used to achieve radial hemostasis, it is important for the clinician to monitor the site and assess perfusion to the hand... A Pulse oximeter should be used to ensure that perfusion is maintained.”
See: Watson & Gorski, Invasive Cardiology, A Manual for Cath Lab Personnel, chapter on “Access site hemostasis”
Unit F, Chapter 13 – Congenital Interventions and Surgery
Question #1000
A child with Tetralogy of Fallot may develop hypoxic spells, where the child becomes anxious, hyperpneic and blue. Therapy indicated includes O2 administration, placing the child in a _____ position, and administering IV _____ medication.
a. Knee-chest, Morphine
b. Knee-chest, Epinephrine
c. Standing, Morphine
b. Standing, Epinephrine
ANSWER: a. Knee-chest position, Morphine.
These hypoxic spells can be terrifying. The child may become extremely cyanotic and hypoxemic. They pant, become anxious and turn blue. This is due to an acute decrease in pulmonary blood flow. It may be fatal if NOT promptly treated.
Therapy involves "squatting" the patient in the "knee-chest position" and morphine to reduce anxiety. Many of these children learn that squatting makes them feel better. It improves oxygenation by increasing systemic resistance and pooling venous blood in the legs. Increasing SVR may temporarily reverse the R-L shunt and cyanosis.
See: Braunwald, chapter on "Congenital Heart Disease."
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