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 Content Part Question Page

IHD–ACS–STEMI– Part 1 – Case From Q1 to Q62 From page 4 to 16

and NSTEMI Scenarios
Part 2 – Short From Q1 to Q48 From page 16 to 24
Questions

ACS Part 1 – Case From Q1 to Q35 From page 25 to 33

COMPLICATIONS Scenarios
(MECHANICAL / Part 2 – Short From Q1 to Q20 From page 33 to 41
ELECTRICAL / Questions
PERICARDIAL)

VHD (AS–AR–MS– Part 1 – Case From Q1 to Q50 From page 42 to 50

MR–TR) Scenarios
Part 2 – Short From Q1 to Q50 From page 50 to 57
Questions

HF – DCM – HOCM – Part 1 – Case From Q1 to Q32 From page 58 to 65

Cardiomyopathies Scenarios
Part 2 – Short From Q1 to Q40 From page 65 to 75
Questions

Arrhythmias – AF – Part 1 – Case From Q1 to Q38 From page 76 to 85

VT – CHB – Brady & Scenarios
Tachy Disorders Part 2 – Short From Q1 to Q73 From page 85 to 103
Questions

Extra Note For More Stress and Concept Reinforcement

Hypertension & From Q1 to Q17 From page 104 to 110

Hypertensive
Disorders in
Pregnancy

Cardiac Evaluation From Q1 to Q15 From page 111 to 119

for Non-Cardiac
Surgery

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 IHD–ACS–STEMI–and NSTEMI
Part 1 – Case Scenarios

Q1

68 y female came in ER with 2 h hx of chest pain - your approach ?

Then he showed me the ECG (Anterior STEMI) and asked what’s next in terms of
management ? Assuming u r in non PCI center.

Then patient in CCU become hypotensive - approach ?

He shared her TTE and asked what’s diagnosis and treatment? It was apical VSR.

Q2

Patient coming with chest pain of 2 hours .how to manage

Q3

Chest pain for 1hr, SBP: 80s, HR: 50s.

Your evaluation and management, ECG: STE inferior e ST depression anterior.

Q4

70 year old male chinese Haj (does not speak arabic or english and no available translator),
brought to you by companions because he looked ill for the last 2 days. ECG showed ST
elevation in inferior and posterior leads he is in CCU now

What to do?

● clinical exam: look for murmurs

● Echo

● activation of cath lab

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 ● cath lab is busy for the next 2 hours due to rush of cases and patient began to be
hypotensive, what to do? (Key is: look for mechanical complications, No role for
thrombolysis, hemodynamic support, echo, wait for cath)

Q5

Case of chronic total occlusion 3 hours after successful PCI and stenting of LAD developed
hypotension

Q6

Case of chronic total occlusion 3 hours after successful PCI and stenting of LAD, with
compromise of Diagonal branch. 2 hours after PCI developed hypotension and shortness of
breath, what is your approach.

● rule out complications of PCI like retroperitoneal hematoma (if femoral access), or
coronary perforation and tamponade.

Dx of tamponade by clinical, echo, and cath

Q7

male patient with high blood pressure 200/100 with severe chest pain , ECG showed acute
inferior myocardial infarction

Management ( take care you must exclude aortic dissection , clinical , echo and TEE or CT)

Q8

NSTE ACS admitted to CCU, dynamic ST depression, recurrent chest pain

What to give?

When to activate cath lab?

Q9

Pt came hypotensive 1wk after PCI, your evaluation.

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 Q10

65 y with chest pain

ECG : inferolateral STEMI

Diagnosis ? What’s next ?

Posterior leads ?

ECG : ST elevation in v7 to v9

Now PCI done successfully to RCA with one DES - in CCU BP 80/50 and hr 50 ?

Asked why he is hypotensive and bradycardic ? Only enumerate possible causes ?

Then showed me an ECG 3 days after while he still in CCU and he is asymptomatic - what’s
diagnosis and what to do next ? ECG was mobitz 1

Q11

female patient 30 years old has chest pain increase with emotion . and her father died of IHD
at age of 70 years

● interpretation of treadmill exercise

● choice of imaging modality

● Coronary angio showed mid LAD significant stenosis, does it affect prognosis

Q12

Inferior STEMI with low BP shocked, chest clear

any clinical tip ? RV leads

Culprit lesion from ECG

impact of RV involvement

Management until PCI

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 Q13

Acute chest pain low risk in ER

Q14

Inferior STEMI in CCU – patient became hypotensive with bradycardia.

What are the possible causes of hypotension and bradycardia in this case?

Enumerate all possible causes.

Q15

Patient presented with anterior MI and developed a new systolic murmur.

What are the differential diagnoses?

How to differentiate between VSR and papillary muscle rupture clinically and by echo?

Q16

Patient with anterior MI three days after event – echo shows apical pseudoaneurysm.

What is the diagnosis and how to differentiate from true aneurysm?

Q17

Inferior MI with clear lungs, BP 80/50 mmHg.

Suspect RV infarction.

How do you confirm it clinically and by ECG?

What is the initial management?

Q18

Patient with cardiogenic shock after acute MI.

Define cardiogenic shock.

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 Enumerate the causes of shock after MI.

How to stabilize the patient before cath lab activation?

Q19

After PCI for LAD chronic total occlusion, patient developed shortness of breath and
hypotension.

How do you approach?

How do you exclude tamponade or perforation?

Q20

Posterior leads (V7 – V9) showing ST elevation in inferior MI.

What is the significance?

Which artery is most probably involved?

How would you document posterior involvement on ECG?

Q21

Patient post-MI developed wide complex tachycardia.

How do you differentiate VT from SVT with aberrancy?

What are the ECG and clinical clues?

What is the immediate management if unstable?

Q22

Patient post-MI developed complete heart block.

What are the most common causes?

How would you manage?

What is the role of temporary pacing?

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 Q23

68-year-old male presented to ER with chest pain, ECG showing ST elevation in inferior
leads with reciprocal depression anteriorly.

Your evaluation and management steps.

Q24

Patient with STEMI, ECG shows ST ↑ in II, III, aVF with ST ↓ in I and aVL.

Identify the culprit lesion.

Explain why ST ↓ in aVL is important in localizing RCA lesion.

Q25

Patient after successful PCI to RCA developed hypotension and bradycardia (BP 80/50
mmHg, HR 50).

Why is he hypotensive and bradycardic?

Enumerate possible mechanisms?

Q26

Patient with inferior STEMI developed complete heart block 24 hours after admission.

What is the explanation?

What is the prognosis?

Do you expect it to recover spontaneously?

Q27

Patient with anterior MI after PCI developed severe shortness of breath and pulmonary
edema.

What are the differential diagnoses?

How do you rule out mechanical complications?

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 Q28

Case of acute chest pain, low risk in ER – describe your full approach, investigations, and
risk assessment tools.

Q29

Patient with chronic coronary syndrome in OPD.

What medications affect survival?

What medications control symptoms?

Q30

Patient with NSTE-ACS on medical therapy – recurrent chest pain in CCU.

When do you activate the cath lab?

What defines high-risk NSTEMI that needs urgent angiography?

Q31

Inferior MI complicated by mechanical rupture – what are the clinical signs that suggest this
complication?

How to confirm by imaging?

Q32

Male patient, 80 years, moderate aortic stenosis (2019), lost follow-up 3 years, now
symptomatic with EF 30 % and low gradient AS.

How to manage “low-flow, low-gradient” aortic stenosis?

(Although AS, it was discussed in context of IHD during the same viva.)

Q33

Patient with previous CABG presents to ER with shock and diffuse ST depression on ECG.

What is your differential diagnosis and management plan?

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 Q34

Patient with STEMI, already on NOAC for AF, comes with fatigue and black stool.

How do you approach anticoagulation in this case?

(Linked to ACS but also overlapping with AF questions.)

Q35

Acute chest pain low risk in ER — explain full initial approach, ECG timing, troponin series,
and risk score selection (TIMI or GRACE).

Q36

After successful PCI and stenting, patient developed chest pain and hypotension two hours
later.

List all possible acute PCI complications: coronary dissection, perforation, stent thrombosis,
tamponade, access site bleeding.

Q37

Anterior MI complicated by heart failure (EF 25 %).

Enumerate possible causes of decompensation (ischemia, arrhythmia, non-compliance,

infection, drug withdrawal).

Q38

Patient with LV dysfunction post-MI (EF 30 %) stable for months, now symptomatic again.

What investigations to repeat before upgrading therapy (echo, ischemia assessment,

electrolytes, compliance check)?

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 Q39

STEMI patient with pulmonary edema and loud holosystolic murmur at apex radiating to
axilla.

What is the likely complication?

What echo findings confirm it?

Q40

Patient with cardiogenic shock, SBP 70 mmHg, cool extremities, elevated JVP, crackles in
chest.

Differentiate cardiogenic from hypovolemic and obstructive shock in this context.

Q41

In acute coronary syndrome, when do you choose primary PCI vs fibrinolysis?

Enumerate indications, time limits, and contraindications.

Q42

Elderly diabetic patient with ACS, eGFR 40 ml/min.

How to adjust antithrombotic and antiplatelet therapy?

Which agents are contraindicated?

Q43

Post-MI patient with persistent ST elevation after 2 weeks.

What are the differential diagnoses (LV aneurysm, reinfarction, pericarditis)?

How to differentiate clinically and by ECG?

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 Q44

During treadmill test, patient developed chest pain and 2 mm ST depression in inferolateral
leads.

Interpretation?

What is next diagnostic step (CTCA / MPI / Coronary Angio)?

Q45

Patient with previous CABG presented with chest pain and ST depression.

Approach to suspected graft occlusion or native vessel disease recurrence.

Q46

Patient in CCU post-STEMI, now hypertensive.

Management strategy for post-MI hypertension and which drugs to avoid immediately (e.g.,
hydralazine causing reflex tachycardia).

Q47

Female 55 y post-MI, on aspirin + clopidogrel + ACE + BB + statin, asks about duration of

DAPT.

Explain duration according to stent type and risk profile.

Q48

Case of inferior MI with RV involvement: echo shows dilated RV and septal shift.

Explain hemodynamic management (fluids, avoid nitrates, cautious inotropes).

Q49

Massive anterior MI → EF 20 %.

When to evaluate for ICD?

When to reassess LV function for device therapy?

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 Q50

Post-MI patient with pericardial rub and mild ST elevation diffusely.

What is your diagnosis?

How to differentiate pericarditis from reinfarction?

Q51

STEMI with cardiogenic shock despite revascularization.

Discuss options of mechanical circulatory support (IABP, Impella, ECMO).

Q52

Patient with IHD on NOAC for AF developed GI bleeding.

Immediate steps and plan for resuming anticoagulation.

Q53

Young male with chest pain and normal coronary angiogram.

Possible causes (MINOCA, myocarditis, Takotsubo, microvascular angina).

Q54

Male 60 y, diabetic, hypertensive, LDL 5 mmol/L, no symptoms.

Management according to guidelines: risk stratification, statin initiation, and role of coronary
calcium score.

Q55

Post-MI follow-up echo shows apical aneurysm with thrombus.

How to manage anticoagulation and imaging follow-up?

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 Q56

Patient with NSTEMI and chronic kidney disease.

Discuss contrast-induced nephropathy prevention measures.

Q57

Patient after thrombolysis for STEMI, no resolution of ST elevation at 90 min.

Next step? (Facilitated or rescue PCI).

Q58

Patient with ACS and severe anemia (Hb 7 g/dL).

How to balance transfusion threshold and ongoing ischemia?

Q59

Hypertensive patient presenting with chest pain.

How to differentiate hypertensive crisis with ischemic ECG changes vs true ACS?

Q60

Post-MI patient on optimal therapy asks about SGLT2 inhibitor use for LV dysfunction.

Explain mechanism and benefits.

Q61

50 year old male unversity staff came for check up, LDL 5, no other risk factors, what to do?

● life style modifications

● look for coronary calcium score

● look for Lp(a) (what is its significance)

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 Q62

patient with chronic coronary syndrome in opd

what medications affect survival?

what medications to cotrol symptoms?

IHD–ACS–STEMI–and NSTEMI

Part 2 – Short Questions, Definitions & Imaging

—————————————————————

Q1 – Definition of Cardiogenic Shock

SBP < 90 mmHg for > 30 min or need for inotropes with signs of end-organ hypoperfusion
(cold extremities, low urine output, altered mentation).

Main causes: LV failure post-MI, mechanical rupture, RV infarction.

──────────────────────────────

Q2 – Initial Management of Cardiogenic Shock before Cath Lab

Oxygen → Fluids (if RV infarct) → Inotropes (Dobutamine) → Vasopressors (Noradrenaline)

→ Early Reperfusion (PCI or CABG if indicated).

──────────────────────────────

Q3 – Bezold–Jarisch Reflex

Reflex bradycardia and hypotension due to inferior MI (vagal afferent activation from LV wall
→ parasympathetic overactivity).

──────────────────────────────

Q4 – Universal Classification of Myocardial Infarction

Type 1 – Spontaneous atherothrombotic MI.

Type 2 – Supply–demand imbalance (anemia, spasm).

Type 3 – Sudden cardiac death before biomarkers obtained.

Type 4 (a/b/c) – PCI-related / stent thrombosis / restenosis.

Type 5 – CABG-related.

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 ──────────────────────────────

Q5 – Diagnostic ECG Criteria of MI

STEMI → ST ↑ ≥ 1 mm in ≥ 2 contiguous leads or new LBBB.

NSTEMI → ST ↓ ≥ 0.5 mm or T-wave inversion + ↑ troponin.

Posterior MI → ST ↓ V1–V3 with tall R waves.

──────────────────────────────

Q6 – Drugs with Mortality Benefit Post-MI

Dual antiplatelet therapy (Aspirin + P2Y12), Beta-blocker, ACEI/ARB, Statin, Aldosterone

antagonist, SGLT2 inhibitor.

──────────────────────────────

Q7 – Causes of Shock in MI

Cardiogenic failure, Mechanical rupture (VSR, MR, free-wall), Arrhythmic (VF, asystole),
Hypovolemic (bleeding).

Examiner may ask: How to distinguish mechanical from LV pump failure clinically.

──────────────────────────────

Q8 – Pericarditis and Dressler’s Syndrome Post-MI

Early Pericarditis → 1–3 days post transmural MI (inflammation).

Dressler’s → 2–6 weeks post MI (autoimmune reaction: fever + pleuritic pain + ↑ ESR).

──────────────────────────────

Q9 – Imaging in Post-MI Complications

Echocardiography → Wall-motion abnormalities, LV thrombus, ruptures.

Cardiac MRI → Viability, fibrosis, micro-vascular obstruction.

Coronary CT → Useful if diagnosis uncertain or low-risk pain.

──────────────────────────────

Q10 – MRI Findings in Infarction vs Myocarditis

Infarction → Sub-endocardial or transmural LGE in coronary distribution.

Myocarditis → Mid-wall or epicardial LGE (non-coronary pattern).

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 ──────────────────────────────

Q11 – LV Aneurysm vs Pseudo-aneurysm

Aneurysm → Broad neck, contains myocardium, low rupture risk.

Pseudo-aneurysm → Narrow neck, free-wall rupture contained by pericardium → High risk,

needs surgery.

──────────────────────────────

Q12 – Differentiate VSR vs Papillary Muscle Rupture on Echo

VSR → Left-to-right shunt at septum with color Doppler jet.

Papillary → Flail leaflet + acute MR jet posteriorly + severe pulmonary edema.

──────────────────────────────

Q13 – No-Reflow Phenomenon after PCI

Persistent micro-vascular obstruction despite open epicardial artery.

Causes → Distal embolization / Reperfusion injury.

Prevention → Adenosine, nicorandil, careful thrombus management.

──────────────────────────────

Q14 – Dressler’s Syndrome Treatment

NSAIDs → Mainstay. Colchicine → for recurrence. Avoid steroids early post-MI (they delay
healing).

──────────────────────────────

Q15 – Killip Classification of Heart Failure in ACS

I – No signs of HF.

II – S3 or mild pulmonary congestion.

III – Frank pulmonary edema.

IV – Cardiogenic shock.

Higher class = worse mortality.

──────────────────────────────

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 Q16 – Reperfusion Injury Definition and Types

Tissue damage after restoring blood flow. Mechanisms: Free radicals, Ca²⁺ overload,
neutrophil infiltration.

Clinical: Myocardial stunning, no-reflow, arrhythmias.

──────────────────────────────

Q17 – Echo Parameters for LV Function Post-MI

LVEF, LVEDD/ESD, regional wall-motion score, strain imaging (normal ≈ –20).

GLS > –15 = LV dysfunction.

──────────────────────────────

Q18 – Papillary Muscle Rupture (Clinical Clues)

Sudden pulmonary edema, new harsh systolic murmur at apex, shock.

Echo → Flail posterior leaflet + acute MR jet.

──────────────────────────────

Q19 – Post-MI Pericardial Effusion vs Tamponade

Effusion → Inflammatory serous collection.

Tamponade → Free-wall leak with Beck’s triad + pulsus paradoxus.

──────────────────────────────

Q20 – Post-MI Arrhythmias

Early → VT/VF (ischemic instability).

Late → Scar-related VT or AF due to LV dilatation.

Treatment based on timing and hemodynamic status.

──────────────────────────────

Q21 – Complications of Acute MI (Summary Review)

1⃣ Electrical → VT, VF, AF, Bradyarrhythmia.

2⃣ Mechanical → VSR, Papillary rupture, Free-wall rupture.

3⃣ Inflammatory → Pericarditis, Dressler’s syndrome.

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 4⃣ Thrombotic → LV thrombus → stroke risk.

5⃣ Heart Failure → Pulmonary edema, Cardiogenic shock.

──────────────────────────────

Q22 – Post-MI LV Thrombus

Occurs within 2 weeks after anterior MI with akinetic apex.

Diagnosis → Echo or Cardiac MRI (best for confirmation).

Treatment → Anticoagulation for 3–6 months (Warfarin INR 2–3 or DOAC if eligible).

──────────────────────────────

Q23 – Indications for Emergency Cath after Thrombolysis

1⃣ Persistent pain > 90 min.

2⃣ < 50 % resolution of ST elevation at 60–90 min.

3⃣ Hemodynamic instability or arrhythmia.

4⃣ Mechanical complication suspected.

──────────────────────────────

Q24 – Re-Infarction vs Re-Occlusion after PCI

Re-infarction → new troponin rise > 20 % after previous fall.

Re-occlusion → abrupt ST elevation + new chest pain.

Differentiate by ECG + angiography.

──────────────────────────────

Q25 – Causes of Failure of Thrombolysis

Late presentation > 12 h, Large thrombus, Inadequate drug dose, Resistance to fibrinolytics,
Persistent occlusion in large proximal lesion.

──────────────────────────────

Q26 – Contraindications to Thrombolytic Therapy

Absolute → Previous ICH, Recent stroke (< 6 months), Aortic dissection, Active bleeding.

Relative → Uncontrolled HTN, Recent major surgery, Pregnancy.

──────────────────────────────

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 Q27 – Complications of Thrombolysis

Major bleeding (GI, ICH), Allergic reaction to streptokinase, Hypotension, Reperfusion

arrhythmias.

──────────────────────────────

Q28 – Late Potential Complications of MI

LV aneurysm, Ventricular tachycardia, Chronic HF, Mitral regurgitation, Thrombo-embolism.

──────────────────────────────

Q29 – Echocardiographic Signs of RV Infarction

• Dilated RV with poor contractility.

• Paradoxical septal motion.

• Normal LV with reduced RV output.

• Inspiratory drop in LV filling (septal shift).

──────────────────────────────

Q30 – Differentiating Cardiac Rupture Types

• Free-wall rupture → Tamponade & PEA arrest.

• Septal rupture → New pan-systolic murmur + shock.

• Papillary muscle rupture → Severe MR + acute pulmonary edema.

──────────────────────────────

Q31 – Papillary Muscle Rupture vs Ischemic MR

Rupture → Sudden severe MR with flail leaflet.

Ischemic MR → Tethering due to LV remodeling (chronic).

Echo key to differentiate.

──────────────────────────────

Q32 – Inferior STEMI with Hypotension

Always suspect RV involvement.

Management → Fluids + Avoid nitrates + Inotropes if needed + Reperfusion.

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 ──────────────────────────────

Q33 – Complications of RV Infarction

Hypotension, Bradycardia (high vagal tone), AV block, Low CO due to impaired RV filling.

──────────────────────────────

Q34 – Posterior MI Recognition

ST depression V1–V3 with tall R waves.

Confirm with posterior leads (V7–V9).

──────────────────────────────

Q35 – Differential Diagnosis of ST Elevation

STEMI, Pericarditis (diffuse concave ST ↑ + PR ↓), LV aneurysm (persistent ST ↑ post MI),

Brugada, Early repolarization.

──────────────────────────────

Q36 – ECG Changes in Pericarditis

Diffuse ST ↑ concave + PR ↓ (lead II, aVF).

Reciprocal ST ↓ in aVR and V1.

──────────────────────────────

Q37 – Diagnostic Role of Cardiac MRI in ACS

Detects myocardial edema, necrosis, micro-vascular obstruction, and tissue viability.

Late Gadolinium Enhancement pattern guides prognosis.

──────────────────────────────

Q38 – Wall-Motion Abnormality Pattern per Coronary Artery

LAD → Anterior, Septal, Apex.

LCX → Lateral, Posterior.

RCA → Inferior ± RV.

Used to localize culprit artery on Echo.

──────────────────────────────

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 Q39 – Pseudo-Normalization of T Wave

T waves in previously inverted leads become upright again → sign of re-ischemia or

re-infarction.

──────────────────────────────

Q40 – Follow-Up After MI

Lifestyle modification, Dual antiplatelets for 12 months, Statin life-long, ACEI/ARB, BB,
Cardiac rehab, Echo at 6–12 weeks to assess LV function.

Q41 – Approach to Chest Pain in ER

1⃣ Rapid assessment: Vital signs + ABCs.

2⃣ Immediate 12-lead ECG within 10 min.

3⃣ Draw troponin (high-sensitivity if available).

4⃣ Classify: STEMI / NSTEMI / Non-cardiac.

5⃣ Give aspirin + oxygen (if hypoxic) + nitrate (if BP allows).

6⃣ Risk stratification → admit to CCU if needed.

──────────────────────────────

Q42 – NSTEMI vs Unstable Angina

NSTEMI → positive troponin, ECG may show ST depression/T inversion.

UA → negative troponin, same ECG pattern.

Management same early, but NSTEMI always needs early invasive strategy.

──────────────────────────────

Q43 – High-Sensitivity Troponin (hs-Trop) Interpretation

• Repeat after 1–3 h.

• Significant change = >20% rise/fall.

• Single positive + rise = acute MI.

• Flat or chronic elevation = chronic injury (CKD, HF).

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 ──────────────────────────────

Q44 – Silent MI (Diabetic / Elderly)

Painless MI, atypical symptoms (dyspnea, fatigue, confusion).

Always check ECG and troponin if unexplained symptoms in diabetic or elderly.

──────────────────────────────

Q45 – Spontaneous Coronary Artery Dissection (SCAD)

Usually young women, peripartum or stress-related.

Angio shows dissection flap or intramural hematoma.

Avoid thrombolytics; conservative if stable; PCI if ongoing ischemia.

──────────────────────────────

Q46 – MINOCA (MI with Non-Obstructive Coronaries)

Criteria: MI evidence + coronaries <50% stenosis.

Causes: spasm, embolism, microvascular disease, SCAD.

Treatment depends on underlying mechanism (antiplatelet, statin, ACEI).

──────────────────────────────

Q47 – Vasospastic (Prinzmetal) Angina

Transient ST elevation at rest, usually early morning.

Triggers: stress, cold, smoking, cocaine.

Treatment: calcium channel blocker, nitrate; avoid beta-blockers.

──────────────────────────────

Q48 – Coronary CT vs Invasive Angiography

CT coronary angiography → for stable chest pain with low–intermediate risk.

Invasive angiography → for high-risk ACS, positive troponin, or unstable cases.

──────────────────────────────

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 ACS COMPLICATIONS (MECHANICAL /
ELECTRICAL / PERICARDIAL)

Part 1 – Case Scenarios

Q1

68-year-old female presented to ER with 2 hours history of chest pain — how will you
approach?

ECG shows Anterior STEMI → next step in management (non-PCI capable centre)?

Later in CCU, patient became hypertensive — approach?

TTE shown → what’s the diagnosis and management?

→ Apical Ventricular Septal Rupture (VSR)

Q2

70-year-old male (Haj patient, Chinese, non-Arabic / non-English speaking) brought by

companions; ill for 2 days.

ECG: ST elevation in inferior + posterior leads.

Patient now in CCU — what will you do?

● Perform clinical exam: look for new murmurs

● Do bedside echocardiography

● Activate cath lab immediately

● If cath lab busy for 2 hours and patient becomes hypotensive, what’s next?

→ Suspect mechanical complications (VSR / papillary rupture / LV rupture), no role

for thrombolysis, initiate hemodynamic support, repeat echo, await cath availability.

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 Q3

65-year-old male with chest pain.

ECG: Inferolateral STEMI.

Diagnosis? Next step?

Posterior leads: ST elevation V7–V9.

After RCA PCI with DES → BP 80/50 mmHg & HR 50 bpm.

→ Enumerate causes of hypotension + bradycardia post-MI.

Later ECG (3 days post-PCI): Mobitz I — what’s diagnosis and what to do?

→ Mobitz I (Wenckebach) — benign, observation only.

Q4

40-year-old patient post-MI develops wide-complex tachycardia.

→ Differentiate between VT and SVT with aberrancy.

Use Brugada Criteria (absent RS complex, RS >100ms, AV dissociation, VT morphology).

Q5

Post-MI patient in CCU developed cardiogenic shock.

→ Define cardiogenic shock.

→ List mechanical complications causing it (VSR, LV free wall rupture, papillary muscle
rupture).

→ Outline emergency management before cath.

Q6

Inferior wall MI patient develops severe hypotension and bradycardia.

→ What is the likely cause?

→ Explain Bezold–Jarisch reflex.

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 Q7

Inferior MI turned out to be aortic dissection — how to suspect and confirm?

→ Pain radiating to back, pulse deficit, BP difference between arms, wide mediastinum on
X-ray, confirmed by CT aortography.

Q8

Post-MI day 3, patient suddenly developed severe pulmonary edema and new systolic
murmur.

→ Diagnosis?

→ Papillary muscle rupture → Acute severe MR.

Q9

Post-MI patient develops pericarditis-like pain and low-grade fever.

→ Diagnosis?

→ Dressler’s syndrome (autoimmune post-MI pericarditis).

Q10

Patient post-recent PCI presenting with shock, muffled heart sounds, and raised JVP.

→ Diagnosis and immediate management?

→ Cardiac tamponade → perform urgent pericardiocentesis.

Q11

60-year-old male with anterior STEMI develops persistent hypotension and rising JVP
despite inotropes.

→ Suspect LV free wall rupture.

→ Diagnosis confirmed by bedside echo showing pericardial effusion with echo-dense clot.

→ Immediate management: pericardiocentesis followed by urgent surgical repair.

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 Q12

Post-MI day 5, patient became acutely dyspneic with a harsh pansystolic murmur at the left
sternal border.

→ Likely diagnosis: Ventricular Septal Rupture (VSR).

→ Confirm by echo (color Doppler: left-to-right shunt).

→ Initial stabilization with IABP and surgical consultation.

Q13

Post-MI patient develops persistent hypotension with clear lungs.

→ Likely cause: RV infarction.

→ How to confirm?

– Right-sided ECG (V4R ST elevation).

– Echo showing RV dilatation with preserved LV function.

→ Avoid nitrates and diuretics; give IV fluids and inotropes if needed.

Q14

Following thrombolysis for STEMI, patient becomes suddenly hypotensive with flank pain.

→ Likely diagnosis: Retroperitoneal hematoma (complication of femoral access).

→ Investigate with CT abdomen; manage with volume resuscitation and possible

intervention if ongoing bleeding.

Q15

Post-PCI patient with sudden drop in Hb and hypotension without external bleeding.

→ Suspect coronary perforation or access site bleed.

→ Immediate echo to rule out tamponade; manage supportively and call interventional team.

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 Q16

Patient with NSTEMI on heparin infusion develops thrombocytopenia.

→ Diagnosis: Heparin-Induced Thrombocytopenia (HIT).

→ Stop all heparin; start non-heparin anticoagulant (argatroban or fondaparinux).

Q17

Acute MI patient develops severe LV failure unresponsive to medical therapy.

→ When to consider mechanical circulatory support?

– Refractory shock despite inotropes/vasopressors.

– Consider IABP, Impella, or ECMO.

Q18

Post-MI patient with recurrent VT/VF.

→ Define “Electrical Storm.”

→ Management:

– Correct electrolytes, use amiodarone, beta-blockers, sedation, and urgent

revascularization if ischemic cause.

Q19

Post-MI patient with sinus bradycardia and hypotension.

→ Likely due to increased vagal tone or RCA infarct affecting SA node.

→ Initial management: atropine; if refractory → temporary pacing.

Q20

Patient with inferior MI develops AV block during hospitalization.

→ Differentiate between transient and persistent AV block post-MI.

– Inferior MI: transient (usually nodal level), improves with reperfusion.

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 – Anterior MI: often infra-Hisian, poor prognosis, may need permanent pacing.

Q21

Post-MI patient with acute pulmonary edema and new systolic murmur at apex; CXR: flash
edema.

→ Likely diagnosis: Papillary muscle rupture → acute severe MR.

→ Confirm by urgent echo (flail posterior leaflet, torrential MR).

→ Stabilize with oxygen, diuretics, vasodilators if BP allows, IABP if shock; urgent surgical
repair is definitive.

Q22

Weeks after large anterior MI, patient has persistent ST elevation on ECG and apical
dyskinesia on echo.

→ Differentiate:

– True LV aneurysm: wide neck, scar wall, persistent ST↑, risk of mural
thrombus/embolism.

– LV pseudoaneurysm: narrow neck, contained rupture, high risk of free rupture.

→ Management: anticoagulate if mural thrombus (typically 3–6 months) for true aneurysm;
urgent surgery for pseudoaneurysm.

Q23

Large anterior MI; echo shows apical mural thrombus.

→ Risk: systemic embolization.

→ Management: start systemic anticoagulation (e.g., warfarin with INR target per local
protocol) typically 3–6 months, repeat imaging for resolution.

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 Q24

Chest pain with pericardial rub after MI.

→ Early post-MI pericarditis (1–3 days) vs Dressler syndrome (weeks).

→ Treatment: high-dose aspirin; avoid non-aspirin NSAIDs early post-MI (healing) and avoid
anticoagulation if significant effusion.

Q25

After reperfusion, telemetry shows accelerated idioventricular rhythm (AIVR), rate 50–110,
fusion beats.

→ Benign reperfusion arrhythmia; usually no treatment unless hemodynamically unstable.

Q26

Hours–days after PCI, patient develops recurrent severe chest pain with new ST elevation.

→ Suspect acute/subacute stent thrombosis (often due to DAPT interruption or resistance).

→ Immediate action: emergent re-PCI; give antithrombotics per protocol.

Q27

Post-thrombolysis/PCI patient with drop in hemoglobin or neurologic symptoms.

→ Bleeding complications (e.g., GI bleed, ICH).

→ Management: stop offending antithrombotics; reverse when indicated (platelets for

antiplatelet-associated major bleed per protocol; specific reversal for anticoagulants); urgent
neuroimaging if ICH suspected.

Q28

After contrast PCI, creatinine rises within 48–72 h.

→ Contrast-associated AKI.

→ Prevention/management: pre-/post-procedure IV hydration, minimize contrast, hold

nephrotoxins (NSAIDs, metformin where indicated), monitor renal function.

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 Q29

During primary PCI, there is no-reflow despite open epicardial artery.

→ Causes: distal embolization, microvascular spasm/edema, reperfusion injury.

→ Management: intracoronary adenosine, nitroprusside or verapamil, gentle aspiration

thrombectomy, optimize anticoagulation.

Q30

Inferior MI with hypotension + bradycardia without overt heart block.

→ Explain the Bezold–Jarisch reflex: vagally mediated bradycardia/hypotension from

inferoposterior ischemia (often RV involvement).

→ Management: atropine, IV fluids; avoid nitrates/diuretics if RV infarct suspected.

Q31

Post-MI day 3–7, sudden cardiac tamponade with PEA arrest.

→ Likely: LV free-wall rupture.

→ Action: emergent pericardiocentesis as bridge to urgent surgery.

Q32

Post-PCI groin access; now back/flank pain, hypotension.

→ Retroperitoneal hematoma (especially with femoral access + anticoagulation).

→ Confirm by CT; resuscitate, reverse anticoagulation if needed, vascular consult.

Q33

NSTEMI patient on heparin develops platelets ↓ >50% from baseline on days 5–10.

→ Heparin-induced thrombocytopenia (HIT).

→ Stop all heparin; start non-heparin anticoagulant (e.g., argatroban, bivalirudin,

fondaparinux), hematology input.

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 Q34

Post-MI recurrent polymorphic VT/VF with prolonged QT.

→ Consider ischemia, electrolyte derangements, QT-prolonging drugs; treat with

magnesium, correct K⁺, stop culprit drugs; urgent revascularization if ongoing ischemia.

Q35

After large MI, patient remains congested with low output despite therapy.

→ Consider cardiogenic shock pathway: invasive monitoring, vasopressors/inotropes as

needed, rapid escalation to IABP/Impella/ECMO plus definitive revascularization or surgery
for mechanical complication.

IHD / ACS / STEMI / NSTEMI – COMPLICATIONS

Part 2 – Short Questions, Definitions & Imaging

Q1

Define mechanical complications of myocardial infarction.

→ Structural damage following infarction leading to acute hemodynamic collapse or heart

failure.

Main types:

● Ventricular Septal Rupture (VSR)

● Papillary Muscle Rupture → Acute MR

● LV Free Wall Rupture → Tamponade

● LV Aneurysm / Pseudoaneurysm

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 Q2

When does each mechanical complication occur post-MI?

Complication Timing post-MI Key Clinical Sign

Papillary muscle rupture Day 2–7 Acute MR, pulmonary

edema

VSR Day 3–5 Harsh pansystolic murmur +

shock

LV free wall rupture Day 5–7 Sudden tamponade / PEA

arrest

True aneurysm Weeks–months Persistent ST↑, HF

Pseudoaneurysm 1–4 weeks Contained rupture, high risk

of rupture

Q3

Differentiate true LV aneurysm vs pseudoaneurysm.

Feature True Aneurysm Pseudoaneurysm

Wall composition Scarred myocardium Pericardium + thrombus

Neck Wide Narrow

Risk of rupture Low Very high

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 ECG Persistent ST↑ May normalize

Management Medical ± anticoagulate Urgent surgery

Q4

Define Dressler’s Syndrome.

→ Autoimmune pericarditis occurring weeks after MI or cardiac surgery.

Features: fever, chest pain, pericardial rub, ↑ESR, mild effusion.

Treatment: High-dose Aspirin (avoid NSAIDs early post-MI).

Q5

Differentiate Early Pericarditis vs Dressler’s Syndrome.

Feature Early Pericarditis Dressler’s Syndrome

Onset 1–3 days post-MI 2–8 weeks post-MI

Cause Inflammation over infarct Autoimmune

ECG Diffuse ST↑, PR↓ Diffuse ST↑ less marked

Treatment High-dose Aspirin Aspirin ± Colchicine

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 Q6

Define Cardiogenic Shock and its diagnostic criteria.

→ State of end-organ hypoperfusion due to inadequate cardiac output despite adequate

volume.

Criteria:

● SBP < 90 mmHg > 30 min

● CI < 2.2 L/min/m²

● PCWP > 15 mmHg

Signs: Cold extremities, ↓Urine, Altered sensorium.

Q7

Explain the Bezold–Jarisch Reflex.

→ Reflex-mediated bradycardia, hypotension, and vasodilatation due to inferoposterior

ischemia.

Seen in: Inferior / RV infarction.

Treatment: Atropine + IV fluids (avoid nitrates, diuretics).

Q8

Explain Reperfusion Arrhythmias.

→ Transient ventricular arrhythmias (AIVR, PVCs, short VT) after reperfusion.

Usually benign — no antiarrhythmic needed.

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 Q9

Define Electrical Storm.

→ ≥3 sustained VT/VF episodes within 24 hours.

Treatment:

● Correct K⁺, Mg²⁺

● IV Amiodarone

● β-blockers (Esmolol)

● Deep sedation ± ablation

Q10

Echo signs of Cardiac Tamponade.

→ Pericardial effusion + RA/RV collapse (diastole), plethoric IVC, respiratory variation of

inflow, swinging heart.

Q11

ECG signs of post-MI complications.

Complication ECG Clue

VSR Persistent ST↑ + Q waves + new murmur

LV aneurysm Persistent ST↑ after MI

Papillary rupture Non-specific, MR signs

Pericarditis Diffuse ST↑ + PR↓

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 RV infarct ST↑ in V4R

Q12

Indications for urgent surgical referral post-MI.

● Mechanical complications (VSR, papillary, LV free wall rupture)

● Pseudoaneurysm

● Refractory shock

● LV rupture / tamponade

Q13

Define No-Reflow Phenomenon.

→ Failure of microvascular reperfusion despite patent epicardial artery.

Causes: Microembolization, edema, reperfusion injury, vasospasm.

Treatment: Intracoronary adenosine / verapamil / nitroprusside.

Q14

Key features of RV Infarction.

→ ST↑ in V4R, hypotension, clear lungs, elevated JVP, Kussmaul’s sign.

Avoid nitrates, give fluids & inotropes.

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 Q15

Role of Echocardiography in ACS complications.

● Detects VSR, papillary rupture, LV rupture.

● Evaluates LV systolic function & MR severity.

● Identifies tamponade, effusion.

● Differentiates true vs pseudoaneurysm.

Q16

Role of Cardiac MRI in ACS complications.

● Defines infarct size, transmurality, viability.

● Differentiates scar vs viable myocardium.

● Detects thrombus, pseudoaneurysm, rupture.

Q17

Mechanical support devices in cardiogenic shock.

● IABP → short-term LV unloading in mechanical complications.

● Impella / ECMO → bridge to recovery or surgery.

● Consider early use if refractory to inotropes.

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 Q18

Define and classify Shock types in post-MI patients.

→ Shock is classified into:

● Cardiogenic: ↓CO (pump failure)

● Hypovolemic: ↓preload

● Obstructive: tamponade, massive PE

● Distributive: septic, anaphylactic

In ACS → cardiogenic is most common.

Q19

Discuss Causes of Shock in MI.

● Pump failure: extensive LV infarction.

● Mechanical: VSR, papillary rupture, LV free wall rupture.

● Arrhythmogenic: VT/VF, bradyarrhythmia.

● Right ventricular infarction: preload failure.

● Hypovolemia / Bleeding: post-lytic or anticoagulant related.

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 Q20

Define TIMI Risk Score for NSTEMI and its prognostic role.

Parameters:

1. Age ≥ 65

2. ≥3 CAD risk factors

3. Known CAD (≥50% stenosis)

4. Aspirin use in past 7 days

5. ≥2 angina episodes in 24h

6. ST deviation ≥0.5 mm

7. ↑Cardiac biomarkers

Score 0–7 → predicts mortality & guides invasive strategy.

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 VHD (AS–AR–MS–MR–TR)
Part 1 – Case Scenarios

Q1

male pt 80years , has moderate aortic stenosis in 2019, missing follow up for 3 years, now
symptomatic with echo showing moderate aortic stenosis with low gradient ,EF=30%

How to manage ( low flow low gradient aortic stenosis )

● low does dobutamic echo showed no significant increase in gradient, same area,
EF35%

● CT valve calcium score is 900

● search for other causes: coronary angio was done showing significant proximal LAD
lesion —> PCI done with improvement of symptoms and LV function.

Q2

male pt 75 years , symptomatic aortic stenosis with low gradient ,EF=25%

How to manage ( low flow low gradient aortic stenosis )

Q3

76 y SOB

TTE: only one clip PLAX - AV calcific and thickened with limited mobility and LV systolic
function mildly impaired-

Asked what can you see here ? What do think about LV function ? Then asked what’s next
step ?

Then showed me 2 different set of numbers for DSE and asked who’s true severe AS and
why ?

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 Q4

Male pt 70 y, African American his Bp 160/100 how to manage?

(Echo later revealed moderate AS during same clinical context, discussion focused on
hypertension management in presence of AS).

Q5

Female patient S/P AVR 5 years ago by metallic prosthesis coming at early pregnancy to
seek advice as regard anticoagulants, mode of delivery and post-partum plan.

Q6

Pregnant lady in last trimester, BP high on labetalol — what will you do?

● Check for preeclampsia.

● If not, add nifedipine and aldomet.

● Discuss importance of magnesium sulfate.

● Advice for future pregnancies (follow BP, aspirin prophylaxis).

Q7

Young lady who got married recently and eager to get pregnant, presented with episodes of
SOB.

Your approach.

MITRAL STENOSIS , PTMC ECHO SCORES.

Q8

25-year-old female with leg and joint swelling who wants to get pregnant — how will you
manage?

→ Rheumatic fever suspected from history → rule out RHD.

Examiner asked: “If I tell you she has mitral stenosis, what will you do?”

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 Q9

Patient with prosthetic valve (mechanical) coming for non-cardiac surgery.

How to bridge oral anticoagulant therapy?

Complications of prosthetic valves — obstructive vs non-obstructive.

Management: thrombolysis or surgery after heart team discussion according to

hemodynamic status.

Q10

Pregnancy with Valvular Heart Disease — what anticoagulant regimen?

Discuss use of warfarin, LMWH, and UFH according to trimester and valve type.

Q11

Patient with mechanical prosthetic valve presented with dyspnea and increased gradient
across valve on echo.

Approach?

Differentiate pannus vs thrombus.

What is the management plan?

Q12

Patient post-MVR presenting with SOB 2 years later — possible causes (prosthetic
dysfunction, paravalvular leak, thrombus).

What investigations to confirm?

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 Q13

Echo assessment of MR severity — what parameters are used?

(Effective regurgitant orifice area, regurgitant volume, vena contracta width, pulmonary vein
flow reversal).

Q14

High-risk criteria in HOCM (included in same exam but discussed in VHD context).

Q15

Patient with severe MR but asymptomatic — what are indications for surgery?

(According to LVESD, LVEF, new AF, pulmonary hypertension).

Q16

Patient with AS and AR mixed lesion — how to evaluate dominance and decide
management?

Q17

Post-valve replacement patient developed hemolysis — what are the causes?

How to evaluate by echo and labs?

Q18

Patient with RHD and MS presenting with severe SOB during pregnancy — what to do?

→ Evaluate echo score for PBMV.

→ Discuss timing and safety of procedure during pregnancy.

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 Q19

Patient with severe AS but normal EF — how to decide timing of surgery?

Discuss role of exercise test and BNP level.

Q20

Echo findings of severe AS — list all parameters (AVA < 1 cm², mean gradient ≥ 40 mmHg,
Vmax ≥ 4 m/s).

Q21

Patient with AR — echo findings of severity (vena contracta, pressure half-time, regurgitant
volume).

Q22

Patient with TR — how to assess severity by echo?

What are surgical indications in isolated TR or combined lesions?

Q23

Case of severe MR due to papillary muscle rupture post-MI — management plan.

Q24

Case of infective endocarditis on prosthetic valve — what antibiotics and duration?

When surgery is indicated?

Q25

Patient post-MVR with new fever — what investigations to rule out endocarditis?

Blood cultures, TEE, Duke criteria.

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 Q26

Mitral stenosis with AF — how to anticoagulate?

What is target INR and duration?

Q27

Mixed mitral valve disease (MS + MR) — how to decide dominant lesion and appropriate
management?

Q28

Severe AS awaiting TAVI — what are anatomical requirements and contraindications for
procedure?

Q29

Prosthetic valve dysfunction — how to interpret echo findings of obstruction vs paravalvular

leak?

Q30

Pregnant woman with mechanical mitral valve on warfarin presented with bleeding — how to
manage anticoagulation urgently?

Q31

Patient with bioprosthetic valve presenting 10 years after surgery with SOB — what to
suspect and how to evaluate degeneration?

Q32

Aortic regurgitation due to infective endocarditis — when to operate urgently?

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 Q33

Patient with MS, MVA = 1.0 cm², mean gradient 12 mmHg, pulmonary hypertension, mild
MR — candidate for PBMV or surgery?

Q34

Patient post-MVR developed hemoptysis — what causes related to high left atrial pressure
or valve thrombosis?

Q35

Severe AR, EF 55%, asymptomatic — what parameters define timing of surgery?

Q36

Patient with severe MR due to flail posterior leaflet — surgical vs percutaneous repair
decision.

Q37

Patient with tricuspid regurgitation secondary to pulmonary hypertension — how to approach

management?

Q38

Patient post-valve replacement developed new anemia — how to differentiate hemolysis

from prosthetic endocarditis?

Q39

Elderly patient with calcific AS and coronary artery disease — combined CABG + AVR
indication.

CardioSense - MADE SIMPLE 48 of 119

 Q40

Bicuspid aortic valve — surgical indication based on aortic root dimension and valve
function.

Q41

Pregnant lady with MS, severe pulmonary hypertension — contraindications for pregnancy
continuation, maternal risk class (WHO classification).

Q42

Post-TAVI patient presenting with conduction disturbance — what is the approach?

Q43

Patient post-PBMV developed severe MR — how to manage this complication?

Q44

Rheumatic MS with LA thrombus — what to do before intervention?

Q45

MS patient with recurrent embolic events despite INR 2.5 — what is your next step?

Q46

Mixed AS-AR lesion — when to intervene surgically, and how gradient/velocity guide
decision?

Q47

Severe MR in ischemic cardiomyopathy — when to refer for surgical repair vs conservative

management?

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 Q48

Patient with MR post-MI — identify mechanism (ischemic vs degenerative).

Q49

AS patient developed heart failure symptoms but preserved EF — what other causes to
consider?

Q50

AR with LV end-diastolic dimension 70 mm, EF 52% — surgical indication?

VHD (AS–AR–MS–MR–TR)

Part 2 – Short Questions, Definitions & Imaging

Q1

Definition and Stages of Hypertension (ESC and ACC).

Q2

Types of Hypertension with Pregnancy.

Q3

Drugs used for treatment of hypertension during pregnancy (safe oral and IV).

Q4

Types of AF.

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 Q5

Echo assessment of MR severity — parameters to evaluate:

● Vena contracta width.

● Effective regurgitant orifice area.

● Regurgitant volume.

● Pulmonary vein flow reversal.

● Left atrial and LV dimensions.

Q6

High-risk criteria in HOCM.

Q7

Definition and stages of Aortic Stenosis severity (by Echo):

● AVA > 1.5 cm² → Mild.

● 1.0–1.5 cm² → Moderate.

● <1.0 cm² → Severe.

● Mean gradient ≥ 40 mmHg.

● Jet velocity ≥ 4.0 m/s.

Q8

Indications of surgery in severe AS — symptomatic, EF < 50 %, undergoing CABG or other

valve surgery.

Q9

Causes of secondary MR (ischemic, functional, rheumatic, degenerative).

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 Q10

Complications of prosthetic valves — obstructive vs non-obstructive:

● Thrombosis

● Pannus formation

● Paravalvular leak

● Endocarditis

● Hemolysis.

Q11

Bridging anticoagulation in prosthetic valves — when to stop warfarin, when to start LMWH,
and when to resume.

Q12

Aortic Regurgitation — causes, clinical findings, and echo signs (pressure half-time, flow
reversal in descending aorta).

Q13

Mitral Stenosis — causes, symptoms, and diagnostic echo parameters (MVA ≤ 1.5 cm² =
severe).

Q14

Mitral valve area calculation by planimetry and pressure half-time.

Q15

Pulmonary hypertension — definition and causes in valvular disease.

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 Q16

Tricuspid regurgitation — echo assessment of severity and surgical indications.

Q17

Prosthetic valve gradients — normal vs abnormal flow; how to interpret increased gradient.

Q18

Rheumatic fever — Jones criteria and long-term prophylaxis.

Q19

Valvular lesions in rheumatic heart disease — common combinations (MS + MR, AR + MS).

Q20

PBMV (Percutaneous Balloon Mitral Valvotomy) — echo score components (Wilkins score:
leaflet mobility, thickening, calcification, subvalvular involvement).

Q21

Indications for PBMV in MS — suitable valve morphology, no LA thrombus, mild MR only.

Q22

Contraindications for PBMV — LA thrombus, moderate/severe MR, heavy calcification,

non-rheumatic etiology.

Q23

Infective Endocarditis — Duke criteria (major & minor).

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 Q24

Indications for surgery in infective endocarditis — refractory heart failure, uncontrolled

infection, large vegetation, recurrent emboli.

Q25

HOCM high-risk criteria and ICD indications (included in same committee under VHD
section).

Q26

WHO classification of pregnancy risk in valvular disease:

● Class I: No detectable risk.

● Class II–III: Moderate risk (MS mild, MR moderate).

● Class IV: Extremely high risk — pregnancy contraindicated (severe MS, severe AS,
PAH).

Q27

Anticoagulation in pregnancy — warfarin vs LMWH vs UFH; dosing and timing in each

trimester.

Q28

Valve replacement options — mechanical vs bioprosthetic; pros and cons, expected

durability, anticoagulation requirement.

Q29

Indications for surgery in AR — symptomatic, EF ≤ 50 %, LVEDD ≥ 70 mm, LVESD ≥ 50

mm.

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 Q30

Indications for surgery in MR — symptomatic severe MR or LVESD > 40 mm, LVEF ≤ 60 %.

Q31

Indications for surgery in TR — severe functional TR during left-sided valve surgery, isolated
severe TR with symptoms.

Q32

Prosthetic valve endocarditis — echo findings and antibiotic regimen (6 weeks).

Q33

Aortic root dimensions in bicuspid valve — when to operate (>50 mm with risk factors or >55
mm without).

Q34

Role of exercise stress echo in asymptomatic severe AS — abnormal BP response or

symptoms = surgical indication.

Q35

Post-valve replacement follow-up — echo schedule and anticoagulation monitoring.

Q36

Pregnancy with mechanical valve — management of anticoagulation in labor and delivery.

Q37

Hemolytic anemia post-valve replacement — causes (paravalvular leak, prosthetic

dysfunction).

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 Q38

Rheumatic MS — long-term prophylaxis (Penicillin G benzathine every 3–4 weeks).

Q39 (Imaging)

ECHO signs of severe MR — large central jet, dense CW signal, pulmonary vein systolic
reversal, LA and LV dilatation.

Q40 (Imaging)

ECHO signs of severe MS — valve thickening, restricted motion, diastolic doming, increased
gradients, MVA ≤ 1.5 cm².

Q41 (Imaging)

ECHO signs of severe AR — flow reversal in descending aorta, short pressure half-time
(<200 ms), enlarged LV.

Q42 (Imaging)

ECHO signs of severe AS — calcified valve, restricted cusp motion, peak velocity ≥ 4 m/s,
mean gradient ≥ 40 mmHg, AVA < 1 cm².

Q43 (Imaging)

TEE evaluation of prosthetic valve — assess motion, thrombus, pannus, regurgitation,

paravalvular leak.

Q44 (Imaging)

MRI evaluation of valvular disease — assess regurgitant fraction, LV volumes, and fibrosis
pattern.

Q45

Causes of prosthetic valve obstruction — pannus, thrombus, patient-prosthesis mismatch.

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 Q46

Causes of paravalvular leak — suture dehiscence, endocarditis, calcified annulus.

Q47

Timing of surgery in mixed valve lesions — guided by dominant lesion and LV function.

Q48

Long-term complications after TAVI — paravalvular leak, conduction block, valve

degeneration.

Q49

Follow-up echo parameters after PBMV — MVA increase, gradient drop, absence of
significant MR.

Q50

Indications of surgery in HOCM — refractory symptoms, LVOT gradient > 50 mmHg, failed
medical therapy.

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 HF – DCM – HOCM –
Cardiomyopathies
Part 1 – Case Scenarios

Q1

DCM case: EF 20–25 %, previously stable, now congested; CXR shows cardiomegaly and
pulmonary congestion.

Exam focus:

● Enumerate causes of decompensation (first answer expected: non-compliance)

● Mention the four prognostic pillars of HF therapy (ACE/ARNI + β-blocker + MRA +

SGLT2i)

Q2

Patient EF 35 %, on β-blocker and has AF.

What will you do?

● Sequence and titration of 4 pillars.

● Continue guideline-directed therapy unless dizziness, postural hypotension, or

intolerance.

● If worsening after uptitration → step back to last tolerated dose.

Q3

70-year-old male, known CHF + DM + severe LV systolic dysfunction, presenting with

progressive dyspnea despite ACE + β-blocker + spironolactone.

Examiner asked about:

● Guideline-based pharmacologic therapy.

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 ● Prognostic benefit of SGLT2 inhibitors (mechanism and outcomes).

Q4

55-year-old female, peripartum cardiomyopathy follow-up; EF 20 %, on bisoprolol 2.5 mg OD

and ramipril 2.5 mg OD.

→ How to adjust medications (up-titration, add MRA, consider ARNI, follow EF trend).

Q5

Post-PCI LV dysfunction (EF 25 %) with new heart failure symptoms.

Discuss:

● Differential diagnosis (ischemic vs non-ischemic).

● When to consider device therapy (ICD/CRT).

Q6

62-year-old known HCM – MRI shows apical aneurysm.

Questions:

● Identify the lesion.

● ICD indication and risk stratification for SCD.

Q7

21-year-old male, three syncopal episodes while playing; ECG: T-wave inversion anterior
leads; echo: HOCM.

Asked:

● Approach to syncope.

● High-risk features for SCD (ICD indications).

CardioSense - MADE SIMPLE 59 of 119

 Q8

HOCM with low BP – how to manage?

● Avoid preload/afterload reduction.

● Use β-blocker, cautious fluids if hypovolemic.

● Avoid nitrates and diuretics.

Q9

Wide-complex tachycardia in HCM patient.

Management if unstable vs stable.

● Unstable → immediate DC cardioversion.

● Stable → antiarrhythmic (amiodarone).

● Avoid AV-nodal blockers if pre-excited.

Q10

17-year-old boy, family history of SCD (brother). Syncope × 3.

Exam → systolic murmur; ECG → LVH; Echo → septum 32 mm + LVOT gradient.

Questions:

● Diagnosis: HOCM.

● How to confirm (Valsalva ↑ murmur).

● Management if LVOT gradient > 55 mmHg (β-blocker → disopyramide →

Mavacamten → septal reduction).

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 Q11

Exam question on Mavacamten:

● What is it? → Cardiac myosin inhibitor.

● Function → reduces contractility, LVOT gradient, and LVH by ≈ 40 %.

● Precaution → may reduce EF; regular Echo mandatory.

Q12

Case of shock post-ACS → echo shows severely reduced EF, clear lungs.

Discuss causes of cardiogenic shock and immediate steps (fluids ↔ inotropes ↔

mechanical support).

Q13

Post-MI LV pseudoaneurysm (echo apical 3-chamber).

Spot diagnosis and management (surgical repair).

Q14

Patient NYHA III, EF 35 %, LBBB.

Discuss CRT indication and expected benefit.

Q15

Dilated cardiomyopathy secondary to chronic alcohol or viral myocarditis — diagnostic

work-up and long-term management.

Q16

Resistant hypertension in DCM patient — secondary causes to rule out (OSA, renal,
endocrine).

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 Q17

HF patient with AF — management priorities:

● Rate vs rhythm control.

● Anticoagulation (CHA₂DS₂-VASc).

● Device therapy timing.

Q18

Post-HF decompensation follow-up — timeline for echo reassessment (3–6 months).

Q19

Echo clip: basal-mid inferolateral contained rupture → diagnosis LV pseudoaneurysm.

Q20

Cardiogenic shock after PCI → evaluate for tamponade, RV infarction, mechanical

complications, and LV failure.

Q21

Patient with advanced HF (Stage D) already on GDMT, still symptomatic (NYHA IV).

Questions:

● What are next-line options? (IV inotropes, LVAD, or transplant).

● When to refer for heart transplantation evaluation?

Q22

Acute decompensated HF — classify based on congestion and perfusion (“warm/dry,

cold/dry, warm/wet, cold/wet”).

Management approach per hemodynamic profile.

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 Q23 (New)

HF patient on β-blocker with bradycardia 45 bpm but stable BP — what to do?

● Do not stop immediately; assess symptoms.

● If symptomatic → dose reduction.

● If asymptomatic → continue and monitor.

Q24

Post-MI patient with EF 35 %, QRS 160 ms, LBBB morphology, persistent NYHA III
symptoms on GDMT.

→ CRT indication (Class I).

Q25

Refractory HF with hypotension on optimal GDMT — what medications may need

down-titration or withdrawal first (e.g., ARNI/ACE before β-blocker if symptomatic
hypotension).

Q26

HF patient with chronic kidney disease (eGFR 28) — which prognostic HF drugs are still
indicated?

● SGLT2 inhibitors can be continued (down to eGFR ≥ 20).

● MRAs with caution if K⁺ < 5.0 and monitor closely.

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 Q27

HOCM with AF — how to manage?

● Rate control (β-blockers, verapamil).

● Rhythm control (amiodarone).

● Anticoagulation (lifelong irrespective of CHA₂DS₂-VASc).

Q28

Takotsubo (stress) cardiomyopathy — diagnostic features and differentiation from ACS on

echo and coronaries.

Q29

Restrictive cardiomyopathy vs constrictive pericarditis — echo/MRI differentiating features.

Q30

End-stage DCM with persistent hypotension despite therapy — when to consider palliative
care approach.

Q31

HF patient recently started on ARNI developed cough and dizziness — what to do?

● Evaluate for symptomatic hypotension; if severe, reduce diuretics first.

● If persistent, switch back temporarily to ACE/ARB until tolerated.

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 Q32

Patient with HOCM on disopyramide developed anticholinergic side effects (urinary

retention, dry mouth).

→ What are alternative management options?

● Optimize β-blocker.

● Consider Mavacamten if available.

● Evaluate for septal myectomy if drug-refractory.

HF – DCM – HOCM – Cardiomyopathies

Part 2 – Short Questions, Definitions & Imaging

Q1

Definition of Heart Failure (HF):

→ Clinical syndrome with typical symptoms (dyspnea, fatigue, edema) caused by structural
or functional cardiac abnormality leading to elevated intracardiac pressures or reduced
cardiac output.

Q2

Classifications of HF (ESC 2023):

● HFrEF → EF < 40 %

● HFmrEF → EF 41–49 %

● HFpEF → EF ≥ 50 % with evidence of diastolic dysfunction

● HFimpEF → Previously < 40 % now > 40 %.

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 Q3

NYHA classification:

I → No limitation.

II → Mild limitation.

III → Marked limitation.

IV → Symptoms at rest.

Q4

ACC/AHA stages of HF:

A: At risk, no structural disease.

B: Structural disease, no symptoms.

C: Structural disease + symptoms.

D: Refractory/end-stage HF.

Q5

Main causes of DCM:

● Ischemic

● Viral myocarditis

● Alcohol/toxins

● Peripartum

● Tachycardia-induced

● Genetic/familial.

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 Q6

HOCM — diagnostic echo criteria:

● LV wall thickness ≥ 15 mm (unexplained).

● SAM of mitral valve.

● LVOT gradient ≥ 30 mmHg (rest) or ≥ 50 mmHg (provoked).

Q7

High-risk features for SCD in HOCM:

● Family history of SCD.

● Syncope (especially exertional).

● Massive LVH ≥ 30 mm.

● Non-sustained VT on Holter.

● Abnormal BP response to exercise.

● LV apical aneurysm or fibrosis on MRI.

Q8

Indications of ICD in HOCM:

● Previous cardiac arrest / sustained VT (Class I).

● Presence of ≥ 1 major risk factor (Class IIa).

Q9

Mechanism of obstruction in HOCM:

→ SAM (systolic anterior motion) of mitral leaflet against septum → dynamic LVOT
obstruction.

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 Q10

Drugs to avoid in HOCM:

● Nitrates

● ACE inhibitors

● Diuretics (cautious)

● Digoxin

(all reduce preload/afterload → worsen obstruction).

Q11

Definition of Peripartum Cardiomyopathy (PPCM):

→ HF developing in last month of pregnancy or ≤ 5 months postpartum with no other

identifiable cause.

Q12

Drugs contraindicated in pregnancy-related HF:

● ACEi / ARBs / ARNIs

● MRAs

● SGLT2 inhibitors.

Safe options: β-blockers (metoprolol), hydralazine, nitrates, diuretics (as needed).

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 Q13

Echo features of DCM:

● LV dilation

● Global hypokinesia

● Reduced EF

● Functional MR/TR

● Increased LV volumes.

Q14

Definition of Cardiogenic Shock:

→ Hypoperfusion due to cardiac pump failure with:

SBP < 90 mmHg > 30 min + signs of hypoperfusion + high filling pressures.

Q15

Types of Cardiomyopathies:

● Dilated (DCM)

● Hypertrophic (HCM/HOCM)

● Restrictive

● Arrhythmogenic RV

● Takotsubo (stress).

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 Q16

Takotsubo (Stress) Cardiomyopathy:

● Usually post emotional stress.

● Apical ballooning on echo.

● Normal coronaries on angiography.

Q17

Restrictive Cardiomyopathy — causes:

Amyloidosis, sarcoidosis, radiation, endomyocardial fibrosis.

Echo findings:

Normal LV size, biatrial enlargement, restrictive filling, preserved EF.

Q18

ECHO findings in HOCM:

● Asymmetric septal hypertrophy.

● SAM of mitral valve.

● LVOT gradient.

● Small LV cavity.

Q19

ECHO findings in DCM:

● LV dilatation.

● EF ↓.

● Secondary MR/TR. • Diastolic dysfunction.

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 Q20

MRI features in HOCM vs DCM:

● HOCM → LGE (fibrosis) in hypertrophied septum or apical aneurysm.

● DCM → Diffuse mid-wall fibrosis, dilated LV.

Q21

Definition of “4 pillars” in HF management:

1. ACEi/ARNI

2. β-blocker

3. MRA

4. SGLT2 inhibitor

All reduce mortality and hospitalization.

Q22

Drugs improving symptoms only (not survival):

● Loop diuretics

● Digoxin (in AF)

● Ivabradine (if HR ≥ 70 bpm on β-blocker).

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 Q23

Device therapy indications:

● ICD → EF ≤ 35 %, NYHA II–III on optimal therapy.

● CRT → EF ≤ 35 %, LBBB, QRS ≥ 150 ms, NYHA II–IV.

Q24

Role of Mavacamten:

→ Cardiac myosin inhibitor ↓ LVOT gradient & wall thickness, may ↓ EF → requires echo
monitoring.

Q25

BNP and NT-proBNP — diagnostic and prognostic value in HF.

Q26

Management of acute decompensated HF:

● Oxygen, IV diuretics, vasodilators (if BP > 100).

● Inotropes if cold and hypotensive.

● Evaluate underlying cause (ACS, arrhythmia, infection).

Q27

Complications of chronic HF:

● Arrhythmias

● Thromboembolism

● Cachexia

● Renal dysfunction. • Hyponatremia.

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 Q28

Echo markers of advanced HF (poor prognosis):

● TAPSE < 14 mm

● RV dysfunction

● Severe MR/TR

● LVEF < 20 %

● Elevated PASP.

Q29

Indications of Heart Transplant:

● Refractory NYHA IV on optimal therapy.

● Peak VO₂ < 12 mL/kg/min.

● Recurrent hospitalizations.

Q30

Contraindications to Heart Transplant:

● Active infection

● Irreversible pulmonary HTN

● Severe renal/hepatic dysfunction

● Non-compliance.

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 Q31

Definition of Cardiac Resynchronization Therapy (CRT):

→ Pacing both ventricles to restore synchrony, improve EF and symptoms.

Q32

When to reassess EF after starting GDMT:

→ 3–6 months after optimization.

Q33

Echo difference between ischemic and non-ischemic DCM:

● Ischemic → regional wall motion abnormalities.

● Non-ischemic → global hypokinesia.

Q34

“Warm–wet–cold–dry” hemodynamic classification in HF and its management strategy.

Q35

Role of SGLT2 inhibitors in non-diabetic HF patients — mechanisms (↓ preload/afterload,

improve energetics, ↓ hospitalization).

Q36

HFpEF — major diagnostic criteria (HFA–PEFF algorithm).

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 Q37

Management of restrictive cardiomyopathy (supportive + treat cause; transplant in advanced

cases).

Q38

Definition and criteria for “Recovered EF (HFimpEF)”.

Q39

Common arrhythmias in HF and their management priority.

Q40

Echo red flags suggesting need for device or advanced therapy.

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 Arrhythmias – AF – VT – CHB – Brady & Tachy
Disorders

Part 1 – Case Scenarios

Q1

85-year-old patient presenting with dizziness.

ECG: Complete Heart Block (CHB).

Questions:

● Diagnosis? → Complete Heart Block.

● Causes? → Degenerative, ischemic (inferior MI), post-surgery, drugs (β-blockers,

CCB, digoxin).

● Management? → Temporary pacing → permanent pacemaker if persistent.

Q2

65-year-old patient with chest pain.

ECG: Inferolateral STEMI.

Questions:

● Diagnosis? → Inferolateral STEMI.

● What’s next? → PCI.

● Posterior leads V7–V9 show ST elevation → confirm posterior involvement.

● After PCI, patient developed hypotension (BP 80/50, HR 50).

→ Enumerate causes: RV infarction, CHB, bradyarrhythmia, cardiogenic shock,

vagal reflex, mechanical complications.

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 Q3

3 days after PCI (RCA DES), patient asymptomatic but ECG shows Mobitz I (Wenckebach).

● Diagnosis? → Mobitz I.

● What to do? → Observation only if asymptomatic; usually transient post-inferior MI.

Q4

45-year-old patient with palpitation.

ECG: Pre-excited AF (irregular wide-complex tachycardia).

Questions:

● Diagnosis? → Pre-excited AF (WPW).

● Management (stable):

• Avoid AV nodal blockers (β-blocker, CCB, digoxin, adenosine).

• Use Procainamide or Ibutilide.

• If unstable → immediate synchronized DC shock.

Q5

22-year-old male presenting with syncope and palpitations.

ECG: Brugada Type 1 pattern.

Questions:

● Diagnosis? → Brugada Syndrome.

● Management? → ICD implantation.

● Avoid: fever, sodium-channel blockers, excessive alcohol.

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 Q6

HOCM patient presenting with wide-complex tachycardia.

Questions:

● Diagnosis? → Ventricular tachycardia secondary to HOCM.

● Why VT? → Fibrosis and myocardial disarray.

● ECG features suggest ischemia? → Q waves, ST changes.

Q7

Case of VT with underlying anterior wall MI (RBBB-like morphology).

● Mechanism: scar-related reentry.

● Management: Amiodarone ± ICD if recurrent.

Q8

Patient with CHB post-inferior MI.

● Mechanism: ischemia of AV node (usually transient).

● Management: monitor; temporary pacing if symptomatic.

Q9

Young patient presenting with loss of consciousness × 3 during exertion.

ECG: deep T-wave inversion anterior leads; echo: HOCM.

● Approach to syncope.

● Identify risk factors for SCD (ICD indication).

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 Q10

Patient with atrial fibrillation (AF).

Questions:

● Management plan in three words → Rate, Rhythm, Anticoagulation.

● CHA₂DS₂-VASc and HAS-BLED score interpretation.

● Anticoagulant choice (NOAC vs Warfarin).

Q11

30-year-old patient with new AF.

● Rate control first (β-blocker, CCB).

● If fails → rhythm control (amiodarone, flecainide).

● If persistent → DC cardioversion.

Q12

Patient with HOCM and new AF.

Questions:

● How to manage?

→ Rate control (β-blockers, verapamil).

→ Rhythm control (amiodarone).

→ Anticoagulation lifelong (regardless of CHA₂DS₂-VASc).

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 Q13

Patient post-TAVI developed new left bundle branch block (LBBB).

Questions:

● What is your approach?

→ Monitor telemetry 48–72 h.

→ If persistent PR prolongation or CHB → permanent pacemaker.

Q14

ECG showing wide QRS tachycardia.

Questions:

● Differential diagnosis? → VT vs SVT with aberrancy.

● Criteria? → Brugada criteria.

● Key differentiating clues:

• AV dissociation (VT).

• Capture/fusion beats (VT).

• Concordance of precordial leads (VT).

Q15

ECG showing narrow complex tachycardia.

Questions:

● Possible diagnoses? → AVNRT, AVRT, AT.

● Acute management:

→ Vagal maneuvers → Adenosine → β-blocker/CCB → DC shock if unstable.

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 Q16

Patient with AF on NOAC presented with fatigue and melena.

Questions:

● What to do? → Stop NOAC, IV PPI, blood transfusion as needed.

● Consider antidote (idarucizumab/andexanet).

● Resume anticoagulation after stabilization.

Q17

Post-operative patient with sinus bradycardia (HR 40) but asymptomatic.

● Observation only; pacing not indicated unless hypotension, syncope, or pauses > 3 s.

Q18

ECG: long QT with polymorphic VT (torsades de pointes).

Questions:

● Causes? → Drugs, hypokalemia, hypomagnesemia, congenital.

● Management? → IV magnesium, stop offending drug, overdrive pacing.

Q19

ECG: short QT interval and VF arrest history.

Diagnosis: Short QT syndrome.

Management: ICD.

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 Q20

Patient presenting with AF and hypotension.

Immediate management → synchronized DC cardioversion.

Q21

Pacemaker malfunction scenario: failure to capture, sense, or pace — how to identify each
on ECG.

Q22

ICD shocks repeatedly — what are possible causes?

● VF storm, lead fracture, inappropriate detection, electrolyte imbalance.

Approach: reprogramming, antiarrhythmic therapy, sedation.

Q23

Brady-tachy syndrome in sick sinus syndrome — diagnosis and pacemaker indication.

Q24

WPW patient develops AF with rapid ventricular response — why AV nodal blockers are
dangerous?

Q25

Reversible causes of CHB:

● Inferior MI, drugs, hypothyroidism, electrolyte abnormalities, Lyme disease.

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 Q26

Persistent bradycardia post-inferior MI — when to insert permanent pacemaker?

→ If persistent > 7 days or associated with symptoms.

Q27

VT in ischemic heart disease — differentiate monomorphic vs polymorphic and

management.

Q28

SVT recurring despite medication — indications for EP study and ablation.

Q29

Patient with ICD presenting with syncope — what to evaluate?

→ Device interrogation, electrolytes, arrhythmia burden, lead integrity.

Q30

Post-cardiac surgery AF — timing, prophylaxis, and rate control approach.

Q31

AF on NOAC scheduled for non-cardiac surgery.

● When to stop? When to resume?

● Any role for heparin bridging?

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 Q32

HAS-BLED score for bleeding risk in AF.

● Enumerate components.

● What BP level is considered “uncontrolled hypertension” in HAS-BLED?

Q33

76-year-old with AF, HTN, DM.

● Calculate CHA₂DS₂-VASc.

● Anticoagulate or not? Which agent?

Q34

WPW patient with recurrent pre-excited AF despite meds.

● When to refer for EP study and ablation?

● Long-term strategy?

Q35

Ischemic cardiomyopathy, EF 30%, 40 days post-MI, NYHA II on GDMT.

● ICD: primary prevention — yes or no?

● What additional criteria matter?

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 Q36

Torsades de pointes (polymorphic VT) on background of prolonged QT.

● Common reversible causes to search for?

● Acute stabilization plan?

Q37

Pacemaker patient with recurrent syncope.

● Differentiate failure to capture vs failure to sense vs failure to pace on ECG.

● Immediate steps in ED?

Q38

ICD patient receiving multiple shocks over 24 h.

● Differential (VT/VF storm, lead issue, inappropriate shocks).

● ED priorities and inpatient plan.

Arrhythmias – AF – VT – CHB – Brady & Tachy

Disorders

Part 2 – Short Questions, Definitions & Imaging

Q1

Definition of Arrhythmia:

→ Any abnormality in heart rate, rhythm, or conduction pattern compared to normal sinus
rhythm.

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 Q2

Classification of arrhythmias:

● By rate: Brady (<60 bpm) / Tachy (>100 bpm).

● By origin: Supraventricular / Ventricular.

● By mechanism: Automaticity / Reentry / Triggered activity.

Q3

Definition of Bradycardia:

→ HR < 60 bpm, may be physiological (athlete) or pathological (SA/AV node disease,

drugs).

Q4

Definition of Tachycardia:

→ HR > 100 bpm, can be regular or irregular, narrow or wide QRS.

Q5

Distinguish between SVT and VT (Brugada Criteria):

1. No RS complex in precordial leads → VT.

2. RS interval > 100 ms → VT.

3. AV dissociation → VT.

4. Morphologic criteria (QRS ≥ 140 ms, extreme axis).

Q6

Define Atrial Fibrillation (AF):

→ Irregularly irregular rhythm, no distinct P waves, variable R–R intervals.

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 Q7

Types of AF:

● Paroxysmal → self-terminates within 7 days.

● Persistent → lasts >7 days or requires cardioversion.

● Long-standing persistent → >12 months.

● Permanent → rhythm accepted, no attempt to restore sinus.

Q8

CHA₂DS₂-VASc Score — components:

C = CHF/LV dysfunction (1)

H = Hypertension (1)

A₂ = Age ≥ 75 (2)

D = Diabetes (1)

S₂ = Stroke/TIA (2)

V = Vascular disease (1)

A = Age 65–74 (1)

Sc = Sex category female (1).

Anticoagulate if ≥ 2 (men) or ≥ 3 (women).

Q9

HAS-BLED Score — components:

Hypertension, Abnormal renal/liver function, Stroke, Bleeding history, Labile INR, Elderly
(>65), Drugs/alcohol.

Uncontrolled BP = >160 mmHg systolic.

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 Q10

Difference between Rate vs Rhythm control in AF:

● Rate → β-blocker, CCB, digoxin.

● Rhythm → Amiodarone, Flecainide, DCCV, Ablation.

Q11

Definition of Complete Heart Block (CHB):

→ No relationship between P waves and QRS (AV dissociation).

Q12

Causes of CHB:

Ischemic (Inferior MI), degenerative fibrosis, post-surgery, drugs (β-blocker, digoxin, CCB).

Q13

Mobitz I (Wenckebach) vs Mobitz II:

● Type I: PR interval progressively lengthens → dropped beat.

● Type II: PR constant → sudden dropped QRS.

Type II → high risk of progression → pacemaker.

Q14

AV block in Inferior vs Anterior MI:

● Inferior → AV nodal → transient, narrow QRS.

● Anterior → Infra-nodal → persistent, wide QRS → pacing.

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 Q15

Indications of Permanent Pacemaker:

● Symptomatic bradycardia.

● CHB.

● Mobitz II.

● Sinus pauses > 3 seconds.

● Alternating bundle branch block.

Q16

Types of Pacemakers:

● Single chamber (A or V).

● Dual chamber (DDD).

● Biventricular (CRT).

● Rate-responsive (R).

Q17

Pacemaker Malfunctions:

● Failure to capture → pacing spike without QRS.

● Failure to sense → spike despite native QRS.

● Failure to pace → no spike when needed.

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 Q18

Indications of ICD:

● Secondary prevention: cardiac arrest, sustained VT/VF.

● Primary prevention: EF ≤ 35 %, NYHA II–III on GDMT, ≥ 40 days post-MI.

Q19

Definition of Torsades de Pointes:

→ Polymorphic VT with twisting QRS axis, usually in prolonged QT.

Q20

Causes of prolonged QT:

● Drugs (amiodarone, macrolides, quinolones, haloperidol).

● Electrolyte disturbances (↓K⁺, ↓Mg²⁺, ↓Ca²⁺).

● Congenital.

Q21

Treatment of Torsades de Pointes:

● IV MgSO₄.

● Stop offending drug.

● Correct electrolytes.

● Overdrive pacing if recurrent.

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 Q22

Definition of VT storm:

→ ≥ 3 episodes of sustained VT/VF within 24 hours.

Management: sedation, IV amiodarone, ICD reprogramming, sympathetic blockade.

Q23

WPW Syndrome — mechanism:

→ Accessory pathway (Bundle of Kent) → pre-excitation (short PR, delta wave, wide QRS).

Q24

Drugs contraindicated in WPW with AF:

→ AV nodal blockers (β-blocker, CCB, digoxin, adenosine).

Preferred: Procainamide, Ibutilide, DC shock if unstable.

Q25

Brugada Syndrome — ECG features:

● Coved ST elevation V1–V3.

● Negative T wave.

● May induce VF → sudden death.

Management: ICD.

Q26

Sick Sinus Syndrome — definition and management.

→ Alternating brady-tachy arrhythmia.

Treatment: Pacemaker ± antiarrhythmic for tachy episodes.

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 Q27

Long QT vs Short QT — ECG difference and associated syndromes.

Q28

Vagal maneuvers — examples and indication (first-line in SVT).

Q29

Mechanism of Adenosine — transient AV nodal block; diagnostic and therapeutic in SVT.

Q30

Postoperative AF — when to anticoagulate and when to stop.

Q31 (Imaging)

Echo role in arrhythmia evaluation:

● LV function in AF or VT.

● Rule out thrombus before cardioversion.

● Evaluate for structural causes (HCM, DCM, valve disease).

Q32 (Imaging)

Cardiac MRI role in arrhythmia:

● Detect myocardial scar/fibrosis (VT substrate).

● Identify ARVC (RV dilation, fatty infiltration).

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 Q33 (Imaging)

12-lead ECG hallmark patterns:

● AF → irregularly irregular rhythm, no P waves.

● Atrial flutter → saw-tooth pattern.

● VT → wide QRS, AV dissociation.

● WPW → short PR, delta wave.

● Brugada → coved ST elevation V1–V3.

Q34

Immediate management of unstable arrhythmias (ACLS 2025):

● Unstable Brady → Atropine → Pacing.

● Unstable Tachy (narrow/wide) → Synchronized DC shock.

● VF/pulseless VT → Unsynchronized defibrillation + CPR + Adrenaline.

Q35

Anticoagulation periprocedural management in AF ablation or cardioversion.

Q36

Algorithm for tachycardia with pulse (AHA 2025) — stepwise.

Q37

Differentiating Pseudo-PEA from true asystole on monitor and management implication.

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 Q38

Holter monitoring indications — unexplained syncope, paroxysmal AF, palpitations.

Q39

EP study indications — recurrent SVT, VT ablation, unclear arrhythmia mechanism.

Q40

Post-pacemaker follow-up — wound, lead thresholds, sensing, battery life, infection signs.

Q41

Left Atrial Appendage (LAA) closure in AF

● Indications?

● When to consider instead of long-term anticoagulation?

Q42

Choosing a NOAC in AF with high GI-bleed risk

● Which agent is preferred?

● Role of PPI co-therapy?

Q43

Peri-cardioversion anticoagulation in AF

● Anticoagulation strategy before/after DCCV.

● TEE-guided alternative pathway.

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 Q44

Anticoagulation rule in HOCM + AF

● Anticoagulate irrespective of CHA₂DS₂-VASc?

————————————————————————

Q45

Post-TAVI new conduction disturbance

● PR prolongation/LBBB/CHB: monitoring period and pacemaker indications?

Q46

AF ablation candidacy

● Symptomatic paroxysmal vs persistent AF; failure/intolerance of ≥1 AAD; key

exclusions.

Q47

Peri-procedural anticoagulation in AF ablation

● Continue vs interrupt NOAC; intraprocedural heparin targets; post-ablation plan.

Q48

NOAC reversal agents

● Idarucizumab vs Andexanet alfa: which for which drug; when to use?

Q49

QTc thresholds

● Diagnostic cut-offs for prolonged QT (male/female); short QT; measurement pitfalls.

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 Q50

Drugs that prolong QT markedly in cardiology practice

● High-yield list (antiarrhythmics/macrolides/fluoroquinolones/antipsychotics).

Q51

Brugada — drugs and conditions to avoid

● Sodium-channel blockers, fever, heavy alcohol; peri-anesthesia considerations.

Q52

Typical vs atypical atrial flutter

● ECG hallmarks; cavotricuspid isthmus dependence; ablation success.

Q53

AVNRT vs AVRT — bedside/ECG differentiators

● RP interval, response to adenosine, pre-excitation clues.

Q54

Tachycardia-induced cardiomyopathy

● When to suspect; time course of EF recovery after rate/rhythm control.

Q55

Anticoagulation in AF with CKD

● eGFR cut-offs; dose adjustments; when to prefer warfarin.

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 Q56

Pericardioversion TOE/TEE pathway

● Timing windows (≥3 weeks vs TEE-guided); post-DCCV anticoagulation duration.

Q57

AF with active GI bleeding

● Stabilization; when to restart anticoagulation; agent choice in high GI-bleed risk.

Q58

ICD: primary vs secondary prevention — timing post-MI

● Minimum days post-MI and post-revascularization; temporary WCD role.

Q59

Wide-complex tachycardia with capture/fusion beats

● Diagnostic implication; acute management pathway.

Q60

Pacemaker indications in sinus node dysfunction

● Symptomatic sinus brady, sinus pauses, chronotropic incompetence; exclusion steps.

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 Q61

Peri-operative management: AF patient for non-cardiac surgery

● Stop/resume timelines by NOAC type and renal function; bridging yes/no.

Q62

AF with HOCM

● Anticoagulation rule regardless of CHA₂DS₂-VASc; rate vs rhythm strategy; ablation

role.

Q63

VT storm — stepwise inpatient algorithm

● Sedation, β-blockade, amiodarone/lidocaine, ICD reprogramming,

sympathectomy/ablation.

Q64

Post-MI transient AV block vs persistent infra-Hisian block

● Prognosis; pacemaker decision criteria.

Q65

LAA closure work-up

● Indications, contraindications, peri-device leak assessment, antithrombotic protocol.

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 Q66

Adenosine — when diagnostic only vs therapeutic

● SVT mechanisms; contraindications (asthma, WPW-AF).

Q67

Holter vs event recorder vs implantable loop recorder

● Indications based on symptom frequency.

Q68

Post-cardioversion sinus pauses/brady

● When to observe vs pace; predictors of SSS unmasked.

Q69

Frequent PVCs and LV dysfunction

● PVC-induced cardiomyopathy threshold (burden %); ablation indications.

Q70

Atrial tachycardia (focal vs macro-reentry)

● ECG clues; adenosine response; ablation success rates.

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 Q71 – 28-year-old female with new-onset AF — CHA₂DS₂-VASc scoring and
anticoagulation choice

Step 1 – Assess Stroke Risk (CHA₂DS₂-VASc Score)

Risk Factor Points

C – Congestive heart failure 1

H – Hypertension 1

A₂ – Age ≥ 75 years 2

D – Diabetes mellitus 1

S₂ – Stroke / TIA / thromboembolism 2

V – Vascular disease (MI, PAD, aortic 1

plaque)

A – Age 65–74 years 1

Sc – Sex category (female) 1

Interpretation:

● 0 (men) / 1 (women) → no anticoagulation

● 1 (men) / 2 (women) → consider anticoagulation

● ≥ 2 (men) / ≥ 3 (women) → anticoagulation indicated

In this case: CHA₂DS₂-VASc = 1 (female sex only) → no anticoagulation required.

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 Step 2 – If score ≥ 2 → start anticoagulation

Drug Class Examples (DOACs) Standard Dose Notes

Factor Xa inhibitors Apixaban / Apixaban 5 mg BID Adjust for renal

Rivaroxaban / Rivaroxaban 20 mg function (CrCl < 50
Edoxaban OD → ↓ dose)

Direct thrombin Dabigatran 150 mg BID Avoid if CrCl < 30

inhibitor ml/min

Vit K antagonist Warfarin Titrate to INR 2–3 Use if mechanical

valve / severe renal
failure

Step 3 – Always review before prescribing: contraindications / renal & hepatic function /
interactions.

Step 4 – Long-term strategy: rate vs rhythm control + echo + lifestyle.

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 Q72 – Anticoagulation in AF — Pharmacology & Renal Excretion of DOACs vs Warfarin

Drug Mechanism Dose Renal Key Notes

Excretion %

Warfarin Vit K antagonist Titrate to INR Hepatic Preferred in

(II, VII, IX, X) 2–3 mechanical
valves / CrCl <
15. Many
interactions.

Dabigatran Direct thrombin 150 mg BID ≈ 80 % renal Avoid if CrCl

(Pradaxa) (IIa) inhibitor (110 mg elderly) < 30. Antidote
→
Idarucizumab.

Rivaroxaban Factor Xa 20 mg OD (15 ≈ 35 % renal Take with food;

(Xarelto) inhibitor mg if CrCl avoid CrCl < 15.
15–49) Reversal →
Andexanet.

Apixaban Factor Xa 5 mg BID (2.5 ≈ 25 % renal Safest in renal

(Eliquis) inhibitor mg BID if impairment.
elderly/low wt) Lowest bleed
risk.

Edoxaban Factor Xa 60 mg OD (30 ≈ 50 % renal Avoid if CrCl >

(Lixiana) inhibitor mg if CrCl 95 (high
15–50) clearance).

Viva Tip: “Dabigatran is most renally excreted (~80 %), so contraindicated if CrCl < 30.
Apixaban least (25 %), Warfarin hepatic.”

Antidotes: Idarucizumab → Dabigatran; Andexanet → Apixaban/Rivaroxaban/Edoxaban.

Check renal function q 6–12 months.

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 Q73 – Compare CHA₂DS₂-VASc and HAS-BLED Scores

Purpose: Stroke risk vs Bleeding risk in AF patients.

Component CHA₂DS₂-VASc HAS-BLED

C CHF HTN (systolic > 160)

H HTN Abnormal renal/liver

A Age ≥ 75 (2 pts) Stroke history

D DM Bleeding history

S Stroke / TIA (2 pts) Labile INR

V Vascular disease Elderly > 65

A Age 65–74 (1 pt) Drugs / Alcohol

Sc Female sex —

Use CHA₂DS₂-VASc to decide who needs anticoagulation, HAS-BLED to estimate bleed

risk but not to withhold therapy.

──────────────────────────────

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 EXTRA NOTE – For More Stress and Concept
Reinforcement
(This section gathers key hypertension and pregnancy-related questions that were
previously mentioned in different chapters. They are reorganized here for easier recall and
focused revision.)

——————————————————

Hypertension & Hypertensive

Disorders in Pregnancy
──────────────────────────────

Q1 – 65-year-old male with hypertension on ACE + CCB + diuretics, previously

controlled, now uncontrolled – what to do?

→ Check compliance, new meds (NSAIDs, decongestants), labs (renal function,

electrolytes).

→ If normal → add spironolactone (25–50 mg daily).

──────────────────────────────

Q2 – 70-year-old African-American male, BP 160/100 mmHg – management plan?

→ Lifestyle + optimize triple therapy (ACE / ARB + CCB + thiazide).

→ Add spironolactone if resistant; evaluate for secondary causes.

──────────────────────────────

Q3 – 55-year-old obese hypertensive on Ca-channel blocker + ACE, BP still high – what

next?

→ Add thiazide diuretic → optimize 4-drug combination.

→ Check for obstructive sleep apnea, renal artery stenosis, endocrine causes.

──────────────────────────────

Q4 – Resistant Hypertension – Definition and Common Causes

BP ≥ 140/90 despite ≥3 drugs (including diuretic) at max dose.

Causes: non-compliance, suboptimal therapy, volume overload, CKD, OSA, Reno-vascular

HTN, pheochromocytoma, Cushing.

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 ──────────────────────────────

Q5 – Classification of Secondary Hypertension and Exam Findings

Renal → renal bruit.

Endocrine → Cushing signs, pheochromocytoma palpitations.

Aortic coarctation → radio-femoral delay, BP difference between arms & legs.

──────────────────────────────

Q6 – Pregnant lady 20 weeks on α-Methyldopa 500 mg TID, BP still high – what to do?

→ Check for preeclampsia (proteinuria, symptoms).

→ If not present → add Labetalol or Nifedipine.

→ Continue close follow-up + monitor fetal growth.

──────────────────────────────

Q7 – Role of Magnesium Sulphate in Preeclampsia / Eclampsia

→ Seizure prophylaxis & treatment.

Dose 4 g IV loading over 15 min → 1–2 g/h maintenance.

Monitor reflexes, urine output, respiration.

Antidote = 10 mL 10% Calcium Gluconate IV slowly.

──────────────────────────────

Q8 – Future Counseling for Pregnant Woman with Hypertension

→ Follow-up BP after delivery (3–5 days then 7–10 days).

→ Long-term risk of chronic HTN and CV disease.

→ Low-dose Aspirin in future pregnancy (75–150 mg from 12–36 weeks).

──────────────────────────────

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 Q9 – Classification of Hypertension in Pregnancy

1⃣ Chronic Hypertension (before 20 weeks or persists post-partum).

2⃣ Gestational Hypertension (after 20 weeks without proteinuria).

3⃣ Preeclampsia (HTN + proteinuria / organ damage).

4⃣ Chronic HTN with superimposed Preeclampsia.

──────────────────────────────

Q10 – Indications for Delivery in Preeclampsia / Eclampsia

• Severe uncontrolled HTN.

• Eclampsia (seizures).

• Pulmonary edema / hypoxemia.

• Renal / hepatic deterioration or HELLP.

• Fetal distress or growth restriction.

──────────────────────────────

Q11 – Low-Dose Aspirin Prophylaxis in High-Risk Pregnancy

Start 75–150 mg daily from 12–16 weeks until 36 weeks gestation.

Indications: history of preeclampsia, chronic HTN, DM, renal disease, multiple gestation.

Benefit: reduces recurrence ≈ 15–20 %.

──────────────────────────────

Q12 – Severe Preeclampsia – “Severe Features” & Delivery Timing

BP ≥ 160/110 or refractory HTN, neuro symptoms, pulmonary edema, platelets < 100k, ↑Cr,
↑AST/ALT, RUQ pain, visual changes.

Deliver ≥ 34 weeks if severe features or any instability (after MgSO₄ + BP control).

──────────────────────────────

Q13 – IV Antihypertensives for Acute Severe HTN in Pregnancy

• Labetalol IV 20 mg → 40 → 80 q10 min (max 220 mg).

• Hydralazine 5–10 mg IV q20–30 min or infusion.

• Nicardipine infusion 2.5–15 mg/h. {Target SBP 140–150 / DBP 90–100; avoid rapid drop.}

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 ──────────────────────────────

Q14 – Post-Partum Hypertension Plan & Next Pregnancy Counseling

• BP follow-up within 7–10 days.

• Safe drugs while breastfeeding: Labetalol, Nifedipine, Enalapril.

• Avoid ARBs during pregnancy.

• Next pregnancy: Aspirin 12–36 weeks + optimize weight & comorbidities.

————————————————————————

Q15 – Resistant Hypertension: Approach & Secondary Causes

Definition:

Blood pressure uncontrolled >140/90 mmHg despite 3 optimally dosed agents, including a
diuretic.

Stepwise Clinical Approach:

1⃣ Confirm true resistance → check compliance, technique, white-coat effect.

2⃣ Review drug classes and interactions (NSAIDs, decongestants, OCPs).

3⃣ Rule out secondary causes (see below).

4⃣ Optimize lifestyle → ↓ salt, weight, alcohol, stress, sleep.

5⃣ Add spironolactone (25–50 mg) if not contraindicated.

Common Secondary Causes & Key Physical Findings:

Cause Clue / Clinical Sign Confirmatory Test

Renal artery stenosis Abdominal bruit CT/MR angiography

Primary aldosteronism Resistant HTN + ↓K⁺ Aldosterone/Renin ratio

Pheochromocytoma Episodic HTN + headache + 24h metanephrines

sweating

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 Cushing’s Central obesity, striae 24h urinary cortisol

Obstructive sleep apnea Obesity, loud snoring, Sleep study

daytime fatigue

Coarctation of aorta Arm–leg BP difference, CT aortogram / Echo

radio-femoral delay

Viva Tip: Always mention sleep apnea as a common overlooked cause in obese patients
with resistant HTN.

Q16– Hypertension in Pregnancy: Types, Management, and Safe Drugs

Types of Hypertension in Pregnancy:

1⃣ Chronic HTN → pre-existing before 20 wks.

2⃣ Gestational HTN → after 20 wks, no proteinuria.

3⃣ Preeclampsia → after 20 wks + proteinuria ± organ dysfunction.

4⃣ Eclampsia → preeclampsia + seizures.

5⃣ Superimposed preeclampsia → chronic HTN + new proteinuria.

First-line Oral Drugs:

Drug Dose Notes

Labetalol 100–400 mg TID First-line safe agent

Methyldopa 250–500 mg TID Long safety record

Nifedipine (SR) 30–60 mg OD Useful if asthma/heart

failure

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 Hydralazine 25–50 mg TID Alternative if refractory

Contraindicated: ACEIs / ARBs / Nitroprusside / Atenolol

Viva Tip:

“Always exclude preeclampsia before escalating antihypertensives.”

“Monitor fetal growth and maternal renal function.”

Q16– Severe Preeclampsia / Eclampsia: Magnesium Sulphate & Delivery Plan

Magnesium Sulphate (MgSO₄)

● Loading dose: 4–6 g IV over 20 min

● Maintenance: 1–2 g/h IV infusion

● Toxicity monitoring:

○ Knee reflex

○ Urine output > 25 ml/h

○ Respiratory rate > 12/min

● Antidote: Calcium gluconate 1 g IV

Delivery Management:

● Aim: shorten 2nd stage of labor, avoid fluid overload.

● Consider Cesarean if unstable.

● Postpartum: monitor BP for ≥72 h, continue therapy, start aspirin next pregnancy (if
indicated).

Viva Tip:

MgSO₄ = only proven drug to prevent seizures in preeclampsia.

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 Q17– Postpartum Hypertension and Long-Term Management

Immediate Postpartum:

● Continue antihypertensives until BP < 140/90 for ≥48 h.

● Safe for breastfeeding: Labetalol, Nifedipine, Enalapril.

Long-Term Plan:

● Evaluate for persistent HTN after 12 weeks.

● Counsel for next pregnancy:

○ Early booking

○ Start low-dose aspirin (75–150 mg daily) from 12 weeks

○ Monitor urine protein & fetal growth serially.

Viva Tip: “Postpartum HTN may unmask chronic essential hypertension — follow up for
at least 6–12 months.”

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 Cardiac Evaluation for Non-Cardiac
Surgery

Q1 – What are the major cardiac risks during non-cardiac surgery?

• Myocardial ischemia or infarction.

• Heart failure decompensation.

• Life-threatening arrhythmias.

• Stroke.

• Sudden cardiac death.

──────────────────────────────

Q2 – Pre-operative cardiac evaluation: when is it indicated?

• History or symptoms of cardiac disease (angina, dyspnea, syncope).

• Known CAD, HF, or valvular disease.

• Poor functional capacity (<4 METs).

• Intermediate or high-risk surgery.

Always do ECG + basic labs; Echo if murmur or LV dysfunction suspected.

──────────────────────────────

Q3 – What is the Revised Cardiac Risk Index (RCRI)?

6 predictors:

1⃣ High-risk surgery.

2⃣ Ischemic heart disease.

3⃣ Heart failure.

4⃣ Cerebrovascular disease.

5⃣ Diabetes on insulin.

6⃣ Creatinine >2.0 mg/dL. ( 0 = low risk, 1–2 = intermediate, ≥3 = high risk.)

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 ──────────────────────────────

Q4 – When to postpone elective non-cardiac surgery after cardiac events?

• After MI without intervention → wait ≥6 weeks.

• After PCI with BMS → ≥1 month.

• After PCI with DES → ≥6 months (prefer 12 if possible).

• After CABG → ≥6 weeks if stable recovery.

──────────────────────────────

Q5 – How to manage antiplatelets perioperatively?

• Continue aspirin for most surgeries (unless neurosurgery/eye with bleeding risk).

• Stop clopidogrel / prasugrel / ticagrelor 5–7 days before elective high-bleed surgery.

• Resume within 24h post-op if hemostasis secure.

• Avoid dual antiplatelet interruption <6 months after DES unless life-saving surgery.

──────────────────────────────

Q6 – How to manage anticoagulants perioperatively?

• Stop warfarin 5 days before; bridge with LMWH if mechanical valve or high
thromboembolic risk.

• Stop NOACs 24–48h before depending on renal function.

• Restart when bleeding risk acceptable.

──────────────────────────────

Q7 – What about β-blockers, ACE inhibitors, and diuretics pre-op?

• Continue β-blockers if already prescribed (don’t start new immediately pre-op).

• Hold ACE inhibitors / ARBs morning of surgery if hypotension risk.

• Continue diuretics only if needed for congestion.

──────────────────────────────

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 Q8 – Post-operative cardiac monitoring: who needs it?

• High-risk surgery, elderly with CAD/HF.

• Continuous ECG monitoring 24–48h.

• Check troponin daily x 2–3 in high-risk patients.

• Optimize volume, avoid anemia, maintain oxygenation.

──────────────────────────────

Q9 – What is the approach to urgent non-cardiac surgery in a high-risk cardiac patient?

• Optimize hemodynamics, give O₂, control BP.

• Continue β-blocker if indicated.

• Use invasive monitoring intra-op.

• Have defibrillator and pacing available.

• Post-op ICU observation.

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 Q10 –Surgical Cardiac Risk Categories (per ESC / ACC 2022)

Risk Level Estimated 30-day Cardiac Examples of Procedures

Event Risk

Low Risk (<1%) Minor or superficial • Cataract or dental

surgeries; usually not extraction• Endoscopy /
requiring cardiac testing colonoscopy• Breast /
thyroid / minor orthopedic•
Plastic surgery

Intermediate Risk (1–5%) Moderate physiological • Intraperitoneal or

stress intrathoracic• Carotid
endarterectomy• Head and
neck surgery• Orthopedic
(hip/knee replacement)•
Prostate surgery

High Risk (>5%) Major fluid shifts or • Major vascular surgery

prolonged hemodynamic (aortic, peripheral)•
stress Emergency surgeries•
Prolonged abdominal or
thoracic procedures• Liver /
pancreas resections

Tip:

High-risk = prolonged, vascular, bleeding, or urgent.

Low-risk = short, superficial, day-case.

──────────────────────────────

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 Q11 – Antiplatelet & Anticoagulant Management Before Surgery

Drug / Class Stop Before Resume After Notes

Surgery Surgery

Aspirin Usually continue Within 24 h post-op Reduces ischemic

unless high bleeding risk; hold only if
risk (neurosurgery, bleeding risk >
eye, prostate) thrombotic risk

Clopidogrel (Plavix) Stop 5 days before Resume 24 h Must not stop <6 mo
elective surgery post-op if post-DES unless
hemostasis secure emergency

Prasugrel (Effient) Stop 7 days before Resume 24–48 h More potent, longer
post-op washout

Ticagrelor (Brilinta) Stop 3–5 days Resume 24–48 h Shorter half-life than
before post-op prasugrel

Warfarin Stop 5 days before Resume 24 h Check INR < 1.5

post-op before surgery;
bridge if mechanical
valve

NOACs (Apixaban, Stop 24–48 h (72 h Resume 24 h No bridging usually

Rivaroxaban, if renal impairment post-op required
Dabigatran, or high-bleed
Edoxaban) surgery)

Key viva phrase:

“Aspirin is usually continued; P2Y12 inhibitors are stopped 5–7 days

pre-op, and dual therapy interruption within 6 months of DES should be
avoided unless life-saving surgery is needed.”.

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 Q12 – Cardiac Risk Stratification Before Non-Cardiac Surgery

Surgical Risk Categories (ACC/AHA 2024 guideline):

Risk Level Typical Procedures Estimated Major Cardiac

Risk (MACE)

Low Risk (<1%) Endoscopy – Dental <1%

extraction – Cataract –
Breast surgery – Superficial
skin procedure

Intermediate Risk (1–5%) Abdominal – Orthopedic – 1–5 %

Urologic – Gynecologic –
Carotid endarterectomy –
Head/neck

High Risk (>5%) Major vascular – Thoracic – >5%

Open aortic or limb
reconstruction

Functional Capacity:

≥ 4 METs (good – proceed) | < 4 METs – evaluate with stress test or

imaging.

Viva Tip: Always mention “MACE risk > 1 % = intermediate/high → need further
evaluation.”

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 Q13 – Peri-Operative Antiplatelet Management (Aspirin / Clopidogrel / Ticagrelor)

Drug When to Stop When to Restart Key Notes

Before Surgery

Aspirin Continue if possible 24 h post-op if Continue for stent <

(except hemostasis 6 wk
neurosurgery) achieved

Clopidogrel Stop 5 days pre-op Resume 24 h Avoid if recent DES

post-op < 6 mo

Prasugrel Stop 7 days pre-op Resume 24–48 h Higher bleeding risk

post-op

Ticagrelor Stop 5 days pre-op Resume 24 h Reversible P2Y12

post-op inhibitor

Viva Tip:

If stent < 1 month → do not stop DAPT. Always consult cardiology before major surgery.

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 Q14 – Peri-Operative Management of Anticoagulants (DOACs / Warfarin)

Stopping Before Surgery:

Drug Stop Before Low Stop Before High Notes

Bleed Risk Bleed Risk

Dabigatran 2 days (normal 4–5 days (if CrCl < 80 % renal excretion
renal) 50) → adjust for renal
function

Rivaroxaban / 1 day 2 days Factor Xa inhibitors

Apixaban / (short half-life)
Edoxaban

Warfarin 5 days prior 5 days prior + check Bridge with LMWH if

INR < 1.5 before mechanical valve /
surgery high risk

Resuming After Surgery:

● Minor surgery → restart after 24 h if hemostasis ok.

● Major surgery → 48–72 h later.

Viva Tip: “Dabigatran needs more days off (pre-op) due to 80 % renal clearance;
Apixaban least renal.”

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 Q15 – Timing of Elective Surgery After Coronary Intervention

Intervention Minimal Delay Before Comments

Elective Surgery

Balloon angioplasty only ≥ 14 days Wait 2 weeks minimum

Bare Metal Stent (BMS) ≥ 30 days Continue aspirin

Drug Eluting Stent (DES) ≥ 6 months (preferably 12 Continue DAPT if < 6 mo

mo)

CABG ≥ 6 weeks Individualize by LV function

Viva Tip: “Never stop dual therapy in first month after DES – life-threatening stent

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