Cardiovascular Practice Questions

Q: A 78-year-old man with a history of myocardial infarction status post coronary artery bypass grafting and a 60-pack-year history of smoking is found deceased in his apartment after not returning calls to his family for the last 2 days. The man was last known to be alive 3 days ago, when his neighbor saw him getting his mail. The family requests an autopsy. On autopsy, the man is found to have a 100% blockage of his left anterior descending artery of his heart and likely passed from sudden cardiac death 2 days prior. Which of the following findings is expected to be found on histologic examination of his damaged myocardium?

Uniform binding of acidophilic dyes. ***Uniform binding of acidophilic dyes*** - This finding, often described as **coagulative necrosis**, is characteristic of myocardial infarction 1-3 days after onset, as enzymes denature and bind to eosin more uniformly. - The patient was found deceased 2 days after his suspected death, placing the myocardial changes within this timeframe. *Fat saponification* - **Fat saponification** is a type of fat necrosis, typically seen in the pancreas or breast, resulting from the enzymatic destruction of fat cells. - It does not occur in the myocardium following an ischemic event. *Cellular debris and lymphocytes* - **Lymphocytes** are generally not the predominant inflammatory cells in the initial stages of a myocardial infarction. - While cellular debris would be present, the primary inflammatory infiltrate in the first 3 days after an MI is typically **neutrophils**, not lymphocytes. *Cystic cavitation* - **Cystic cavitation** is a characteristic feature of liquefactive necrosis, which occurs in the brain following an ischemic stroke, but not in the heart. - The heart undergoes **coagulative necrosis** after an MI. *Cellular debris and macrophages* - **Macrophages** become prominent later in the healing process of a myocardial infarction, typically starting around **3-7 days** after the event. - At the 2-day mark, the dominant cells would still be neutrophils and necrotic myocytes.

Q: A 48-year-old man with a lengthy history of angina is brought to the emergency department after the acute onset of severe chest pain that started 40 minutes ago. Unlike previous episodes of chest pain, this one is unresponsive to nitroglycerin. His medical history is significant for hypertension, type 2 diabetes mellitus, and hyperlipidemia. His current medications include lisinopril, metformin, and simvastatin. His blood pressure is 130/80 mm Hg, heart rate is 88/min, respiratory rate is 25/min, and temperature is 36.6°C (97.8°F). An ECG shows ST-segment elevation in leads avF and V1-V3. He is administered aspirin, nasal oxygen, morphine, and clopidogrel; additionally, myocardial reperfusion is performed. He is discharged within 2 weeks. He comes back 3 weeks later for follow-up. Which of the following gross findings are expected to be found in the myocardium of this patient at this time?

White scar tissue. ***White scar tissue*** - Three weeks post-MI, the healing process is advanced, characterized by the formation of **dense fibrous scar tissue**, which appears white. - This scar tissue replaces the necrotic myocardium and is primarily composed of **collagen**, signifying the completion of the repair phase. *Pale infarcted tissue* - This finding is typical of an **acute myocardial infarction** during the initial hours to days, before significant inflammatory response or healing has occurred. - At 3 weeks, the tissue would have undergone significant remodeling, and the infarct would no longer appear pale and unorganized. *Coagulation necrosis* - **Coagulation necrosis** is the hallmark microscopic feature of an acute ischemic injury, visible within hours to a few days after the infarct. - Grossly, this might present as pallor, but at 3 weeks, the necrotic tissue would have been largely cleared or replaced. *Yellow necrotic area* - A **yellow necrotic area** usually appears around 3 to 10 days post-MI, as neutrophils begin to break down the dead myocardial cells. - This reflects the peak of the inflammatory process and early reabsorption of necrotic debris, but it would have progressed further by 3 weeks. *Red granulation tissue* - **Red granulation tissue** begins to form within 1-2 weeks post-MI, as macrophages clear cellular debris and fibroblasts deposit collagen. - While present, it would be transitioning into mature fibrous scar tissue by 3 weeks, which is predominantly white.

Q: A 42-year-old man with systolic heart failure secondary to amyloidosis undergoes heart transplantation. The donor heart is obtained from a 17-year-old boy who died in a motor vehicle collision. Examination of the donor heart during the procedure shows a flat, yellow-white discoloration with an irregular border on the luminal surface of the aorta. A biopsy of this lesion is most likely to show which of the following?

Lipoprotein-laden macrophages. ***Lipoprotein-laden macrophages*** - The description of a flat, yellow-white discolored lesion with an irregular border on the luminal surface of the aorta in a 17-year-old is classic for a **fatty streak**, the earliest lesion of **atherosclerosis**. - Fatty streaks are histologically characterized by the accumulation of **macrophages that have ingested oxidized lipoproteins**, appearing as foam cells within the intima. *Apoptotic smooth muscle cells* - While apoptosis of various cell types, including smooth muscle cells, can occur in advanced atherosclerotic lesions, it is not the primary or defining feature of an early **fatty streak**. - **Apoptosis** contributes to the necrotic core formation in later stages of plaque development, not the initial yellow-white discoloration of a fatty streak. *Necrotic cell debris* - **Necrotic cell debris** is a prominent feature of more advanced, **complicated atherosclerotic plaques**, forming the necrotic core. - In a **fatty streak**, the cells are primarily viable foam cells, and significant necrosis is not yet present. *Proteoglycan accumulation* - **Proteoglycan accumulation** occurs in the arterial intima and is involved in the retention of lipoproteins, contributing to the development of atherosclerosis. - However, the immediate and most characteristic histological finding of the **yellow-white discoloration** in a fatty streak is the lipid-laden macrophage. *Collagen deposition* - **Collagen deposition** is a key feature of the fibrous cap in **advanced atherosclerotic plaques**, laid down by migrating smooth muscle cells. - It is not the primary histological characteristic of an early, flat, yellow-white **fatty streak**.

Q: An 80-year-old man is admitted to the hospital after the sudden onset of sub-sternal chest pain and shortness of breath while sitting in a chair. He has hypertension and type 2 diabetes mellitus. He has smoked 1 pack of cigarettes daily for 42 years. Four days after admission, he becomes tachycardic and then loses consciousness; the cardiac monitor shows irregular electrical activity. Cardiac examination shows a new systolic murmur at the apex. Despite appropriate measures, he dies. Microscopic evaluation of the myocardium is most likely to show which of the following?

Hyperemic granulation tissue with abundance of macrophages. ***Hyperemic granulation tissue with abundance of macrophages*** - The patient experienced an **acute myocardial infarction (MI)** with subsequent complications, including sudden death occurring 4 days after the initial event. - At 4 days post-MI, the characteristic microscopic finding is **hyperemic granulation tissue**, where **macrophages** are prominent in clearing necrotic debris, and new blood vessels start to form. *Wavy myocardial fibers without inflammatory cells* - This finding is typically seen within the first few hours (0-4 hours) after an MI, representing early irreversible ischemic injury before significant inflammation begins. - The patient died 4 days later; therefore, more advanced changes would be expected. *Coagulative necrosis with dense neutrophilic infiltrate* - This stage is observed between 12 hours and 3 days post-MI, as neutrophils infiltrate the necrotic tissue to initiate breakdown and removal of dead cells. - While neutrophil infiltration is important, the primary characteristic at 4 days would shift towards macrophage predominance and early granulation tissue. *Low cellularity with dense, non-contractile scar tissue* - This describes the **final stage of MI healing**, typically observed several weeks to months after the event, when the necrotic tissue has been completely replaced by a mature collagenous scar. - At 4 days, the process is still actively inflammatory and reparative. *Dense granulation tissue with collagenous scar formation* - This stage represents a later phase of healing, usually from 1 to 2 weeks post-MI, where the granulation tissue becomes more dense and collagen deposition increases. - While granulation tissue is present at 4 days, it would be described as more hyperemic with a prominent macrophage presence rather than dense collagenous scar formation.

Q: A 53-year-old woman presents with a severe headache, nausea, and vomiting for the past 48 hours. Vitals show a blood pressure of 220/134 mm Hg and a pulse of 88/min. Urinalysis shows a 2+ proteinuria and RBC casts. Which of the following renal lesions is most likely to be seen in this patient?

Fibrinoid necrosis. ***Fibrinoid necrosis*** - The patient's presentation with **severe hypertension** (220/134 mm Hg), **proteinuria**, and **RBC casts** is highly suggestive of a **hypertensive crisis with malignant nephrosclerosis**. - **Fibrinoid necrosis** refers to the accumulation of **fibrin-like material** in the walls of arterioles, a characteristic pathological finding in **malignant hypertension** leading to vascular damage in the kidney. *Papillary necrosis* - This condition is typically associated with **analgesic nephropathy**, **diabetes mellitus**, and **urinary tract obstruction** or **sickle cell disease**. - While it can cause renal dysfunction, it does not directly explain the acute severe hypertension and RBC casts unique to hypertensive emergencies. *Acute tubular necrosis (ATN)* - While ATN can cause **acute kidney injury**, it is usually characterized by **muddy brown casts** and is often precipitated by **ischemic** or **nephrotoxic insults**. - The prominent hypertension and RBC casts point away from primary ATN in this context. *Acute pyelonephritis* - Acute pyelonephritis is an **infection of the kidney** characterized by **fever**, **flank pain**, and **pyuria** (white blood cells in urine), usually not severe hypertension and RBC casts. - The main findings in this patient are related to vascular damage, not infection. *Acute interstitial nephritis (AIN)* - AIN is often caused by **drug reactions** or systemic diseases, presenting with **fever**, **rash**, **eosinophilia**, and **white blood cell casts**. - The clinical picture of severe hypertension and RBC casts is not typical for AIN.

Q: A 62-year-old woman is evaluated for fatigue 6 months after placement of a mechanical valve due to aortic stenosis. She does not drink alcohol or smoke cigarettes. A complete blood count reports hemoglobin of 9.5 g/dL and a reticulocyte percentage of 5.8%. Platelet and leukocyte counts are within their normal ranges. The patient's physician suspects traumatic hemolysis from the patient's mechanical valve as the cause of her anemia. Which of the following peripheral blood smear findings would most support this diagnosis?

RBC fragments and schistocytes. ***RBC fragments and schistocytes*** - The presence of **RBC fragments** (schistocytes) on a peripheral blood smear is the hallmark of **microangiopathic hemolytic anemia** (MAHA), often seen in traumatic hemolysis caused by mechanical heart valves. - Mechanical valves can create **high-shear stress**, physically damaging red blood cells as they pass through, leading to their fragmentation. *Bite cells and Heinz bodies* - **Bite cells** and **Heinz bodies** are characteristic of **oxidative hemolysis**, typically seen in G6PD deficiency or reactions to certain drugs. - They are formed when denatured hemoglobin precipitates and is removed by splenic macrophages, leaving "bites" out of the red cells. *Round macrocytes and target cells* - **Round macrocytes** are characteristic of **folate or B12 deficiency**, which leads to impaired DNA synthesis and ineffective erythropoiesis. - **Target cells** are often associated with **thalassemia**, liver disease, or hemoglobinopathies, where there is an increased surface area to volume ratio of the red blood cell. *Macrocytes and hypersegmented neutrophils* - **Macrocytes** and **hypersegmented neutrophils** (>5 lobes) are classic findings in **megaloblastic anemias** due to **vitamin B12** or **folate deficiency**. - These findings indicate impaired DNA synthesis affecting both erythroid and myeloid cell lines. *Sickle cells and target cells* - **Sickle cells** are pathognomonic for **sickle cell anemia**, a genetic disorder characterized by abnormal hemoglobin leading to red blood cell distortion under low oxygen conditions. - While **target cells** can sometimes be seen in sickle cell disease, their primary association is with other hemoglobinopathies or liver disease, and sickle cells are not a feature of traumatic hemolysis.

Q: A 12-year-old girl with an autosomal dominant mutation in myosin-binding protein C is being evaluated by a pediatric cardiologist. The family history reveals that the patient's father died suddenly at age 33 while running a half-marathon. What was the likely finding on histological evaluation of her father's heart at autopsy?

Myocyte disarray. ***Myocyte disarray*** - The patient's father likely had **hypertrophic cardiomyopathy (HCM)**, given the autosomal dominant inheritance, mutation in myosin-binding protein C, and sudden cardiac death during exertion. - **Myocyte disarray** (disorganized bundles of cardiomyocytes) is a classic histological hallmark of HCM and a key feature contributing to arrhythmias and sudden death. *Amyloid deposits* - **Amyloidosis** is characterized by the deposition of abnormal protein fibrils in tissues, which can cause restrictive cardiomyopathy. - While amyloid can mimic some features of HCM, it is not associated with mutations in **myosin-binding protein C** and would show specific apple-green birefringence with Congo red stain, not myocyte disarray. *Wavy myocytes* - **Wavy myocytes** are a histological finding typically seen in early myocardial infarction due to cellular stretching and retraction. - This finding is indicative of myocardial ischemia and necrosis, not the chronic structural abnormalities found in genetic cardiomyopathies like HCM. *Eosinophilic infiltration* - **Eosinophilic infiltration** of the myocardium is characteristic of **Loeffler endocarditis** or other forms of eosinophilic myocarditis. - This is an inflammatory condition and is not a feature of hypertrophic cardiomyopathy or associated with mutations in myosin-binding protein C. *Viral particles* - The presence of **viral particles** within myocytes suggests **viral myocarditis**, which can lead to dilated cardiomyopathy or acute heart failure. - This is an infectious cause of heart disease and is distinct from the genetic structural abnormalities seen in hypertrophic cardiomyopathy.

Q: A 58-year-old man presents to the emergency department with severe right leg pain accompanied by tingling and weakness. His condition started suddenly 3 hours ago when he was watching a movie. His medical history is remarkable for type 2 diabetes mellitus and hypertension. He has been smoking 20–30 cigarettes per day for the past 35 years. His vital signs include a blood pressure of 149/85 mm Hg, a temperature of 36.9°C (98.4°F), and an irregular pulse of 96/min. On physical examination, his right popliteal and posterior tibial pulses are absent. His right leg is pale and cold. Which of the following is the most likely diagnosis?

Acute limb ischemia. ***Acute limb ischemia*** - The sudden onset of **severe leg pain**, **tingling**, **weakness**, and the **six P's** (pain, pallor, pulselessness, paresthesias, poikilothermia, and paralysis) are classic signs of acute limb ischemia. - The patient's history of **smoking**, **hypertension**, **diabetes**, and an **irregular pulse** (suggesting atrial fibrillation) are significant risk factors for **thromboembolism**, which is a common cause of acute limb ischemia. *Buerger's disease* - This condition primarily affects **small and medium-sized arteries and veins** in the limbs and is strongly associated with **heavy tobacco use**. - However, it typically presents with **distal extremity ischemia**, superficial phlebitis, and Raynaud's phenomenon, rather than the sudden, severe, large vessel occlusion described here. *Leriche syndrome* - This syndrome involves **atherosclerotic occlusion of the distal aorta** at or just below the renal arteries, affecting both lower limbs. - It classically presents with a triad of **bilateral buttock/thigh claudication**, **impotence**, and **absent femoral pulses**, which does not align with the unilateral symptoms and specific pulse deficits described in the case. *CREST syndrome* - CREST (Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasias) is a subtype of **systemic sclerosis**, a **connective tissue disease**. - Its symptoms are unrelated to the acute vascular event presented, which involves sudden limb ischemia. *Deep vein thrombosis* - DVT primarily involves the formation of a **blood clot in a deep vein**, leading to symptoms like **swelling**, **pain**, and **redness** in the affected limb. - It does not typically cause the **acute pallor**, **coldness**, **pulselessness**, and severe neurologic deficits (tingling, weakness) seen with arterial occlusion.

Question 1

A 78-year-old man with a history of myocardial infarction status post coronary artery bypass grafting and a 60-pack-year history of smoking is found deceased in his apartment after not returning calls to his family for the last 2 days. The man was last known to be alive 3 days ago, when his neighbor saw him getting his mail. The family requests an autopsy. On autopsy, the man is found to have a 100% blockage of his left anterior descending artery of his heart and likely passed from sudden cardiac death 2 days prior. Which of the following findings is expected to be found on histologic examination of his damaged myocardium?

Accepted Answer

Uniform binding of acidophilic dyes

Answer

Fat saponification

Answer

Cellular debris and lymphocytes

Answer

Cystic cavitation

Answer

Cellular debris and macrophages

Question 2

A 48-year-old man with a lengthy history of angina is brought to the emergency department after the acute onset of severe chest pain that started 40 minutes ago. Unlike previous episodes of chest pain, this one is unresponsive to nitroglycerin. His medical history is significant for hypertension, type 2 diabetes mellitus, and hyperlipidemia. His current medications include lisinopril, metformin, and simvastatin. His blood pressure is 130/80 mm Hg, heart rate is 88/min, respiratory rate is 25/min, and temperature is 36.6°C (97.8°F). An ECG shows ST-segment elevation in leads avF and V1-V3. He is administered aspirin, nasal oxygen, morphine, and clopidogrel; additionally, myocardial reperfusion is performed. He is discharged within 2 weeks. He comes back 3 weeks later for follow-up. Which of the following gross findings are expected to be found in the myocardium of this patient at this time?

Accepted Answer

White scar tissue

Answer

Pale infarcted tissue

Answer

Coagulation necrosis

Answer

Yellow necrotic area

Answer

Red granulation tissue

Question 3

A 50-year-old man is brought to the hospital after being found unresponsive in his bed in the morning. He is declared dead on arrival in the emergency room. His wife states that he always had uncontrolled hypertension despite being on multiple medications. An autopsy is performed, and the cause of his death is found to be a hemorrhage in his right basal ganglia. On microscopic examination, the branches of the renal artery have concentric endothelial proliferation with prominent narrowing of the lumen resulting in focal ischemia and hemorrhage of the renal parenchyma. Which of the following is most likely related to the findings in this patient?

Accepted Answer

Raised renin level in the blood

Answer

Raised cholesterol level in the blood

Answer

Elevated ammonia level in the blood

Answer

Raised calcium level in the blood

Answer

Elevated C-reactive protein in the blood

Question 4

A 42-year-old man with systolic heart failure secondary to amyloidosis undergoes heart transplantation. The donor heart is obtained from a 17-year-old boy who died in a motor vehicle collision. Examination of the donor heart during the procedure shows a flat, yellow-white discoloration with an irregular border on the luminal surface of the aorta. A biopsy of this lesion is most likely to show which of the following?

Accepted Answer

Lipoprotein-laden macrophages

Answer

Apoptotic smooth muscle cells

Answer

Necrotic cell debris

Answer

Proteoglycan accumulation

Answer

Collagen deposition

Question 5

An 80-year-old man is admitted to the hospital after the sudden onset of sub-sternal chest pain and shortness of breath while sitting in a chair. He has hypertension and type 2 diabetes mellitus. He has smoked 1 pack of cigarettes daily for 42 years. Four days after admission, he becomes tachycardic and then loses consciousness; the cardiac monitor shows irregular electrical activity. Cardiac examination shows a new systolic murmur at the apex. Despite appropriate measures, he dies. Microscopic evaluation of the myocardium is most likely to show which of the following?

Accepted Answer

Hyperemic granulation tissue with abundance of macrophages

Answer

Wavy myocardial fibers without inflammatory cells

Answer

Coagulative necrosis with dense neutrophilic infiltrate

Answer

Low cellularity with dense, non-contractile scar tissue

Answer

Dense granulation tissue with collagenous scar formation

Question 6

A 53-year-old woman presents with a severe headache, nausea, and vomiting for the past 48 hours. Vitals show a blood pressure of 220/134 mm Hg and a pulse of 88/min. Urinalysis shows a 2+ proteinuria and RBC casts. Which of the following renal lesions is most likely to be seen in this patient?

Accepted Answer

Fibrinoid necrosis

Answer

Papillary necrosis

Answer

Acute tubular necrosis (ATN)

Answer

Acute pyelonephritis

Answer

Acute interstitial nephritis (AIN)

Question 7

A 62-year-old woman is evaluated for fatigue 6 months after placement of a mechanical valve due to aortic stenosis. She does not drink alcohol or smoke cigarettes. A complete blood count reports hemoglobin of 9.5 g/dL and a reticulocyte percentage of 5.8%. Platelet and leukocyte counts are within their normal ranges. The patient's physician suspects traumatic hemolysis from the patient's mechanical valve as the cause of her anemia. Which of the following peripheral blood smear findings would most support this diagnosis?

Accepted Answer

RBC fragments and schistocytes

Answer

Bite cells and Heinz bodies

Answer

Round macrocytes and target cells

Answer

Macrocytes and hypersegmented neutrophils

Answer

Sickle cells and target cells

Question 8

A 72-year-old man comes to the physician because of a 6-month history of intermittent dull abdominal pain that radiates to the back. He has smoked one pack of cigarettes daily for 50 years. His blood pressure is 145/80 mm Hg. Abdominal examination shows generalized tenderness and a pulsatile mass in the periumbilical region on deep palpation. Further evaluation of the affected blood vessel is most likely to show which of the following?

Accepted Answer

Fragmentation of elastic tissue in the tunica media

Answer

Obliterative inflammation of the vasa vasorum

Answer

Formation of giant cells in the tunica media

Answer

Necrotizing inflammation of the entire vessel wall

Answer

Accumulation of foam cells in the tunica intima

Question 9

A 12-year-old girl with an autosomal dominant mutation in myosin-binding protein C is being evaluated by a pediatric cardiologist. The family history reveals that the patient's father died suddenly at age 33 while running a half-marathon. What was the likely finding on histological evaluation of her father's heart at autopsy?

Accepted Answer

Myocyte disarray

Answer

Amyloid deposits

Answer

Wavy myocytes

Answer

Eosinophilic infiltration

Answer

Viral particles

Question 10

A 58-year-old man presents to the emergency department with severe right leg pain accompanied by tingling and weakness. His condition started suddenly 3 hours ago when he was watching a movie. His medical history is remarkable for type 2 diabetes mellitus and hypertension. He has been smoking 20–30 cigarettes per day for the past 35 years. His vital signs include a blood pressure of 149/85 mm Hg, a temperature of 36.9°C (98.4°F), and an irregular pulse of 96/min. On physical examination, his right popliteal and posterior tibial pulses are absent. His right leg is pale and cold. Which of the following is the most likely diagnosis?

Accepted Answer

Acute limb ischemia

Answer

Buerger's disease

Answer

Leriche syndrome

Answer

CREST syndrome

Answer

Deep vein thrombosis

Cardiovascular — MCQs

Cardiovascular — MCQs

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