Multiple Choice Questions (MCQ)

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Category: Cardiology--->CT, CMR, And Nuclear Imaging
Page: 10

Question 46#Print Question

The patient is a 56-year-old man with hypertension, diabetes, and obesity who was admitted 6 months ago to an outside hospital with a late presentation of an anterior MI. He presented approximately 3 days post MI and underwent cardiac catheterization at 1 week, which showed a total occlusion in the mid-left anterior descending artery (LAD), severe stenoses of the first and second diagonals, and no significant disease in either the right coronary artery (RCA) or left circumflex artery (LCx). The patient was then referred to your hospital for revascularization. The patient, however, failed to show for his appointment and finally presented 8 months later with CP and SOB. Prior to revascularization you order a positron emission tomography (PET) rubidium (Rb)/fluorodeoxyglucose (FDG) using Rubidium82 /F18A (flourine-18–labeled deoxyglucose) to determine the degree of inducible ischemia and viability. The images obtained are in Figure below.

Rubidium/FDG PET scan with the stress images displayed on top, the rest images next, and the delayed metabolic FDG images displayed on the bottom.

The images from the PET scan demonstrate:

a. Scar in the LAD territory
b. Inducible ischemia in the LAD territory
c. Hibernating Myocardium in the LAD territory
d. A combination of inducible ischemia and hibernation in the LAD territory
e. Scar in the RCA territory

Question 47#Print Question

The patient is a 75-year-old man with hypertension, diabetes, hypercholesterolemia, and coronary artery disease (CAD) who is 10 years s/p CABG: left internal mammary artery to LAD, saphenous vein graft (SVG) to RCA, and SVG to first obtuse marginal. He is asymptomatic on a good medical regimen, although he is relatively sedentary. TTE demonstrated normal LV systolic function with left ventricular ejection fraction (LVEF) 60%, moderately severe left ventricular hypertrophy (LVH), and no significant valvular disease. The patient is now sent for cardiac evaluation prior to surgery on his dilated abdominal aorta (7.5 cm in diameter). An adenosine nuclear stress test is ordered for preoperative risk assessment. During the adenosine stress he remained asymptomatic although he developed 2-mm ST depressions in I, L, and V2–V6 . There were no significant changes in blood pressure. Figure below shows the scan.

The scan demonstrates:

a. Marked attenuation
b. Multivessel ischemia
c. Infarct but no ischemia
d. Mixture of infarct and ischemia
e. Motion artifact

Question 48#Print Question

The patient is a 62-year-old man with CAD risk factors including diabetes (16 years), hypertension, family history of CAD, and obesity. The patient had a silent inferior MI 2 years earlier detected by ECG. The patient is now sent for preoperative evaluation for bilateral knee surgery. The patient has no CP with exertion; however, his exercise capacity is limited by knee pain. He does occasionally have mild post-prandial dyspnea. His medications include insulin, a statin, an angiotensin-converting enzyme inhibitor, a βblocker, and an aspirin. A pharmacologic dual-isotope (Thal/Tc) scan was performed and is shown in Figure below.

A pharmacologic (adenosine) dual-isotope (Thal/Tc) scan with the stress images displayed on top with the resting images below.

The gated images showed an LVEF of 42% with a wall motion abnormality in the inferolateral wall. There were no ECG changes or symptoms during the adenosine infusion. The rest and post-stress images demonstrate

a. Scarred RCA/LCx territory
b. Scarred LAD territory
c. Normal test with artifacts
d. Scar and ischemia in the LCx/RCA territory
e. Scar and ischemia in the LAD territory

Question 49#Print Question

The patient is a 60-year-old man with hypertension, diabetes (newly diagnosed), and CAD (s/p percutaneous coronary intervention with drugeluting stent in his mid-LAD 5 years ago, and bare metal stent to distal RCA, and a posteroventricular branch 7 years ago). The patient is now sent for symptom evaluation. The patient notes the onset of CPs with exertion while playing squash approximately 2 months ago. The pain occurs only with activity and resolves within a few minutes with rest. He denies other associated symptoms or discomfort at rest. A treadmill nuclear stress test was performed. The patient exercised using a standard Bruce protocol having completed eight metabolic equivalents and reached 98% maximum predicted heart rate (MPHR). There was a normal ST-segment response to stress, and there was no CP with exercise. He did, however, develop new ST depressions in recovery and new atrial fibrillation in recovery, requiring treatment with β-blockers. The scan images are shown in Figure below. 

An exercise technetium-99m nuclear stress test with the stress images with the gated images (currently still) on top, the post-stress images next, and the resting images on the bottom.

The appropriate interpretation of this scan is:

a. RCA territory infarct
b. LAD territory infarct
c. RCA territory ischemia
d. LAD infarct with peri-infarct ischemia
e. LAD and LCx versus left main ischemia

Question 50#Print Question

A 19-year-old young woman is referred to your office for evaluation of congestive heart failure (CHF) and MR. She has a history of complete heart block and has previously undergone pacemaker implantation. On physical examination, her heart rate is 85 bpm, respiratory rate of 16, and blood pressure 108/65 mmHg. Her jugular venous pulse is visible 6 cm above the sternal angle at 45 degrees. The point of maximum impulse is sustained but normal in location. She has a grade II/VI holosystolic murmur at the apex that radiates to the axilla. There is trivial bilateral pedal edema. A posterior– anterior and lateral chest X-ray demonstrates mild cardiomegaly. A TTE reveals moderately reduced LV systolic function with an EF of 35%. There is 2+ to 3+ posteriorly directed MR. A cardiac CT with contrast is obtained to evaluate the coronary arteries (Fig. below A and B).

A. Double-oblique image of the aortic root at the level of the right and left sinuses of Valsalva. Ao, aorta; LA, left atrium; RCA, right coronary artery; RVOT, right ventricular outflow tract. B. Oblique axial image at the level of the left coronary artery origin. LCA, left coronary artery.

Which of the following is true regarding this patient’s condition? 

a. This condition is a common cause of sudden cardiac death in athletes
b. The anomaly shown represents origin of the left coronary artery from the right coronary ostium
c. Surgical reimplantation of the anomalous coronary artery is indicated
d. Patients with this condition who survive past childhood often present with varying degrees of heart failure, myocardial ischemia, and MR, depending on the development of collateral circulation
e. This condition is usually inoperable and best left alone

Category: Cardiology--->CT, CMR, And Nuclear Imaging
Page: 10 of 10