MCQs on Other CVS Disorders

Written by Dr. Daniel Fraser (MBBS, FRACP) – Physician

Question 1

Robert, 67 years old, presents to your clinic for evaluation of increasing left leg pain for the past 6 months. He describes the pain as aching, which is brought on after walking one or two blocks and alleviated with rest. However, it has been worse recently, starting after walking shorter distances and taking more time to get better. He also mentions that sometimes he wakes up in the middle of the night due to leg pain. He smokes 5–10 cigarettes a day and drinks socially. He denies any remarkable medical condition except hypercholesterolemia for which he is on atorvastatin 10 mg daily. On examination, he has a blood pressure of 142/91 mmHg, pulse rate of 88 bpm and a BMI of 32. Compared to the right side, the left leg has less hair. He has a left ankle/brachial index (ABI) of 0.3 on the left side and 1.0 on the right. Which one of the following investigations is the option of choice to establish a certain diagnosis in Robert?

A) Duplex ultrasound
B) Digital subtraction catheter (DSA) angiography
C) Arteriography
D) CT angiography
E) Magnetic resonance angiography

Correct Answer: A) Duplex ultrasound.

Robert has typical features of peripheral arterial disease (PAD)—intermittent claudication, progression of symptoms, night pain, and an ABI of 0.3, which suggests severe ischemia in the left leg. Although the ABI points toward the need for possible intervention, a confirmatory diagnostic investigation is still necessary.

The most appropriate non-invasive method to confirm PAD and evaluate the anatomical location, severity, and hemodynamic significance of the lesion is duplex ultrasound. It combines B-mode imaging (for anatomic structure) with Doppler flow analysis (for blood velocity), making it an excellent initial test with high sensitivity and specificity for diagnosing PAD.

While CT angiography (option D) and MR angiography (option E) provide detailed vascular imaging, they are usually reserved for pre-interventional planning rather than initial diagnosis. They also involve contrast use, which can pose risks in patients with renal impairment or allergies.

Catheter DSA angiography (option B) is considered the gold standard, but it is invasive, carries risks of complications, and is not typically used as the first-line test.

Arteriography (option C) is another term for angiography and, like DSA, is mainly used before interventions, not for routine diagnosis.

In summary, duplex ultrasound is the first-choice investigation for confirming PAD in a safe, accessible, and cost-effective manner.

Question 2

A 65-year-old female patient undergoes percutaneous coronary intervention and stent placement through the femoral artery and is started on aspirin and clopidogrel. After 24 hours, she develops a pulsatile painful mass in the groin where the catheter was inserted. Which one of the following is the definitive treatment of this mass?

A) Massage and application of compression
B) Surgical repair
C) Vitamin K
D) Angiography
E) Injection of thrombin into the mass

Correct Answer: E) Injection of thrombin into the mass

This clinical scenario describes a pseudoaneurysm, a common complication of femoral artery catheterization. A pseudoaneurysm is a hematoma that forms outside the arterial wall due to a leaking hole, contained by surrounding fibromuscular tissue but still communicating with the artery.

Pseudoaneurysms occur in up to 7.5% of femoral artery catheterizations and can cause complications such as distal embolization, neurovascular compression, rupture, and hemorrhage.

The patient presents with a painful, pulsatile groin mass, sometimes with an audible bruit. Diagnosis is confirmed with duplex Doppler ultrasound showing a characteristic ‘to-and-fro’ waveform in the neck of the pseudoaneurysm.

Ultrasound-guided thrombin injection into the pseudoaneurysm sac is now the preferred and definitive treatment, with a success rate of 97%. The procedure involves injecting thrombin under continuous ultrasound guidance, avoiding the neck of the pseudoaneurysm.

(Option A) Ultrasound-guided compression was previously standard but requires prolonged compression (up to 120 minutes), causes patient discomfort, and has higher recurrence rates, especially with large pseudoaneurysms.

(Option B) Surgical repair is reserved for cases where the limb is threatened or percutaneous treatment fails. It was the standard treatment before 1985.

(Option C) Vitamin K has no role in treating pseudoaneurysms and stopping antiplatelet agents such as clopidogrel is contraindicated soon after angioplasty.

(Option D) Angiography is indicated only if there is acute vessel occlusion due to embolism causing limb ischemia, not for treating the pseudoaneurysm itself.

Question 3

A 57-year-old man presents to the Emergency Department with sudden onset of severe pain and pallor in the left lower limb. He is a known case of ischemic heart disease (IHD) and peripheral vascular disease (PVD). On examination, left femoral pulse is felt, but the left popliteal pulse is absent. Which one of the following is the most appropriate next step in management?

A) Intravenous unfractionated heparin (UFH)
B) Low molecular weight heparin (LMWH)
C) Warfarin
D) Verapamil
E) Embolectomy

Correct Answer: A) Intravenous unfractionated heparin (UFH)

Sudden onset of pain and pallor in the limb suggests acute limb ischemia. The absence of a popliteal pulse confirms arterial occlusion. Once this clinical diagnosis is made, immediate anticoagulation with intravenous UFH is the most appropriate step to prevent thrombus propagation and distal thrombosis due to stasis.

Unfractionated heparin is preferred over other anticoagulants in this setting because its effects can be rapidly reversed with protamine sulfate, which is critical since the patient may soon require surgical or catheter-based intervention. A loading dose of 5000 IU is typically given, followed by a continuous infusion adjusted based on activated partial thromboplastin time (aPTT).

(Option B) LMWH has similar efficacy but is not preferred in unstable patients or when an invasive procedure may be required, as its anticoagulant effects are not rapidly reversible.

(Option C) Warfarin is used for long-term anticoagulation and has a delayed onset. It may also initially be prothrombotic, making it unsuitable for acute management.

(Option D) Verapamil, a calcium channel blocker, has no role in the treatment of acute limb ischemia.

(Option E) Embolectomy is a definitive treatment option, but heparin must be started immediately to stabilize the patient before deciding on further interventions.

Author – Dr. Daniel Fraser (MBBS, FRACP)

Dr. Daniel Fraser is a consultant physician with extensive expertise in diagnosing and managing complex medical conditions. His special interests include cardiovascular health, metabolic disorders, and preventative medicine.

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2. Cardiology Module

2.1 ECG

2.2 Acute Coronary Syndrome

2.3 Heart Failure

2.4 Hypertension

2.5 Valvular Heart Diseases

2.6 Other CVS Disorders

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