Fellows Corner: QUIZ

Abstract

20 questions in basic sciences, drug interactions, imaging, important signs, advances, and congenital heart disease are presented. The answers are given after the questions.

1. Which of the following medications is considered the fifth pillar in the management of heart failure?

ARNI

SGLT2i

Direct sGC stimulators

Isosorbide dinitrate and hydralazine

2. A 75-year-old male, hypertensive, chronic smoker, with COPD, has been diagnosed to have heart failure with reduced ejection fraction (LVEF: 20%). He has been prescribed digoxin 0.5 mg OD along with other GDMT. He had a heart rate of 96 min⁻¹. He was already on a beta-blocker. The next day, the resident doing the rounds found his heart rate to be 66 min⁻¹. He found a prominent “a” wave in the assessment of JVP. His serum creatinine was 1.9 mg dL⁻¹; however, he was euvolemic with good urine output. The consultant stopped digoxin and the beta-blocker and advised close monitoring. What is that beta-blocker which increases serum digoxin levels?

Metoprolol

Atenolol

Bisoprolol

Carvedilol

3. The electrocardiogram of the patient is as follows. What is the diagnosis?

Complete heart block

Atrial tachycardia with 2:1 block

2:1 AV block

Atrial flutter with 2:1 block

4. An 86-year-old male was diagnosed with left hemiparesis. He was hypertensive and diabetic. There was no previous history of cardiac disease. He was sent for a cardiological source of emboli. An ECG was ordered, which showed sinus rhythm, broad P wave of 130 msec, biphasic P wave in inferior leads, and P wave axis of +30°. What is the name of the syndrome?

Lown syndrome

Bayes syndrome

Mc Crutz syndrome

Katz Welch syndrome

5. What is the ultra-short-acting beta-blocker approved for managing postoperative atrial fibrillation?

Esmolol

Landiolol

Carvedilol

Nebivolol

6. What is McGinn White’s sign in the following electrocardiogram?

Sinus tachycardia

T wave inversions in V1-V3

S1Q3T3

S1S2S3

7. What is the most common anomalous origin of the coronaries?

Split RCA

Left circumflex artery from the right coronary sinus

Split LAD

Separate conus

8. What is Inclisiran?

Small interfering RNA inhibiting translation of PCSK9

NPC1LI protein blocker

ATP citrate lyase inhibitor

Antisense oligonucleotide inhibitor

9. What is Milvexian?

Factor XIa inhibitor

Factor Xa inhibitor

Direct thrombin inhibitor

Factor XIII inhibitor

10. What does the M mode of the below image show?

AML prolapse

L wave

SAM

EPSS > 8 mm

11. What does the arrow in the below still 2D echo image point out?

Pleural effusion

Pericardial effusion

Mirror image artifact

Aortic dissection

12. The jugular venous pressure (JVP) has a predictable relationship with pulmonary artery wedge pressure (PAWP). A JVP of >12 mm Hg predicted PAWP >22 mm Hg by 88% in which of the following trials?

BNP

ESCAPE

EVEREST

EMPA REG

13. What is cardiac power output (CPO) in a patient with acute anterior wall ST-elevation myocardial infarction and left ventricular failure? His mean arterial pressure was 60 mm Hg and cardiac output calculated on echo was 2.91l min⁻¹.

0.48

0.38

0.58

0.68

14. Which of the following drugs have no mortality benefit?

Nitrates

Beta-blockers

Trimetazidine

RAAS blockers

15. Which among the following beta-blockers is not potent than propranolol (considering propranolol = 1)?

Carvedilol

Metoprolol

Bisoprolol

Labetalol

16. Dome and dart P wave in lead V1 in electrocardiogram is suggestive of which of the following?

Dextrocardia

Left atrial ectopic rhythm

Biatrial enlargement

Mitral stenosis

17. Varying intensity of the first heart sound from a booming (bruit de canon) to virtual inaudibility is seen in which of the following?

Mitral stenosis with atrial fibrillation

Constant 2:1 AV block

First-degree AV block

Congenital complete heart block

18. Which of the following is the proposed algorithm for the evaluation of causes of r’ in V1 and V2 is?

Wernicke algorithm

Vereckei algorithm

Brugada algorithm

Baranchuk algorithm

19. Malignant mutation in hypertrophic cardiomyopathy is which of the following?

Arg 403 Gln

Gln 403 Arg

Arg 304 Gln

Gln 304 Arg

20. Rocker bottom feet and polyvalvular dysplasia are characteristic of which of the following?

Trisomy 19

Trisomy 18

Trisomy 13

Trisomy 21

ANSWERS

1. C. Direct soluble guanylate cyclase stimulators

Balestrieri G, Sciatti E, D’isa S, D’elia E, Senni M. Heart failure therapy: The fifth card. Eur Heart J Suppl. April 2023;25(suppl B):B140-B143.

2. D. Carvedilol

Though all the beta-blockers have the risk of high-grade AV block and bradycardia, carvedilol specifically increases digoxin levels by 15%.

Tighe DA, Tran MT, Donovan JL, Cook JR. Cardiology Drug Guide. Jone and Bartlett Learning, MA, USA. 2010; 58.

3. C. 2:1 AV block

There are two p waves for each QRS complex; every alternating p wave is not conducting through the AV node. 2:1 AV block.

4. B. Bayes syndrome

https://doi.org/10.1161/CIRCULATIONAHA.117.032333

Circulation. 2018;137:200-202.

5. B. Landiolol

Domanovits H, Wolzt M, Stix G. Landiolol: Pharmacology and its use for rate control in atrial fibrillation in an emergency setting. Eur Heart J Suppl. 2018 January;20(Suppl A):A1-A3.

6. C. S1Q3T3

McGinn S, White PD. Acute cor pulmonale resulting from pulmonary embolism. JAMA. 1935;104:1473-1480.

7. B. Left circumflex artery from the right coronary sinus

Yuksel S, Meric M, Soylu K, Gulel O, Zengin H, Demircan S, Yilmaz O, Sahin M. The primary anomalies of coronary artery origin and course: A coronary angiographic analysis of 16,573 patients. Exp Clin Cardiol. 2013 Spring;18(2):121-123.

8. A. Small interfering RNA inhibiting translation of PCSK9

Fitzgerald K, White S, Borodovsky A, et al. A highly durable RNAi therapeutic inhibitor of PCSK9. N Engl J Med. 2017;376:41-51.

9. A. Factor XIa inhibitor

Weitz JI, Strony J, Ageno W, et al. Milvexian for the prevention of venous thromboembolism. N Engl J Med. 2021 December 2;385(23):2161-2172.

10. B. L wave

Kerut, EK. The mitral L-wave: A relatively common but ignored useful finding. Echocardiography. 2008;25:548-550.

11. C. Mirror image artifact

Bertrand PB, Levine RA, Isselbacher EM, Vandervoort PM. Fact or artifact in two-dimensional echocardiography: Avoiding misdiagnosis and missed diagnosis. J Am Soc Echocardiogr. 2016 May;29(5):381-391.

12. B. ESCAPE trial

Bonow RO, Mann DL, Zipes DP et al. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, Philadelphia: Elsevier Science, 12th edition. 2022; 135.

13. B. MAP * (CO/451) 0.38

Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, Philadelphia: Elsevier Science, 12th edition. 2022; 686.

14. A. Nitrates

Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, Philadelphia: Elsevier Science, 12th edition. 2022;709.

15. D. Labetalol—0.3 potency

Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, Philadelphia: Elsevier Science, 12th edition. 2022; 758.

16. B. Left atrial ectopic rhythm

Ariane J. Marelli, Jamil A. Aboulhosn, 3 - The cardiac malpositions, Perloff’s Clinical Recognition of Congenital Heart Disease, Elsevier, 7th edition. 2023; 16-38.

17. D. Congenital complete heart block

Ariane J. Marelli, Jamil A. Aboulhosn, 4 - Isolated congenital complete heart block, Perloff’s Clinical Recognition of Congenital Heart Disease, Elsevier, 7th edition. 2023; 39-47.

18. D. Baranchuk algorithm

Fuster V, Harrington RA, Narula J, Eapen ZJ. eds. Hurst’s The Heart, 14e. McGraw Hill; 2017, Chapter 12. Surface electrocardiography, 331.

19. A. Arg 403 Gln

Epstein ND, Cohn GM, Cyran F, Fananapazir L. Differences in clinical expression of hypertrophic cardiomyopathy are associated with two distinct mutations in the beta-myosin heavy chain gene. A 908Leu—Val mutation and a 403Arg—Gln mutation. Circulation. 1992;86:345-352.

20. B. Trisomy 18

Matsuoka R, Misugi K, Goto A, Gilbert EF, Ando M. Congenital heart anomalies in the trisomy 18 syndrome, with reference to congenital polyvalvular disease. Am J Med Genet. 1983 April;14(4):657-668.