Summary of All 11 Questions Answered

Q41 - Pericarditis

• Etiology: viral/idiopathic (85%), TB, bacterial, SLE, RA, uremia, neoplastic, drug-induced, post-MI (Dressler), radiation
• Physical exam: Ewart's sign, pericardial friction rub (3 components at LLSB), pericardial knock in constrictive
• ECG: 4 stages - diffuse concave ST elevation + PR depression → T inversion → normalization; differs from STEMI (diffuse, no reciprocal changes)
• Treatment: Aspirin 650 mg q6h + Colchicine 0.5-1.2 mg/day x 3 months; etiology-specific (anti-TB, dialysis for uremia, corticosteroids only if NSAIDs fail); pericardiectomy for constrictive disease and refractory recurrences

Q42 - Cardiac Tamponade

• Beck's triad: Hypotension + elevated JVP + muffled heart sounds
• Hemodynamics: Equalization of diastolic pressures; pulsus paradoxus; electrical alternans on ECG
• Echo gold standard: RV diastolic collapse, plethoric IVC, respiratory variation in mitral inflow
• Treatment: Echo-guided pericardiocentesis; surgical drainage for organized/multiloculated effusions, purulent pericarditis, trauma

Q43/Q44 - Myocarditis

• Etiology: Coxsackievirus B (West), Chagas (worldwide); toxic (checkpoint inhibitors increasingly important)
• Pathogenesis: 3 phases - direct viral injury → immune-mediated injury (molecular mimicry) → chronic autoimmune cardiomyopathy
• Clinical variants: Fulminant (acute, best prognosis), Acute non-fulminant, Chronic active, Chronic persistent
• Mayo Clinic classification: Lymphocytic, Eosinophilic, Giant cell (most aggressive), Granulomatous, Chagas
• Gold standard diagnosis: CMR (Lake Louise criteria) + Endomyocardial biopsy (Dallas criteria + immunohistochemistry + PCR)
• Treatment: Activity restriction 6 months + GDMT (ACE-I, BB, diuretics, SGLT2i) + Mechanical circulatory support for fulminant; immunosuppression for giant cell/autoimmune; no immunosuppression for viral

Q45 - Congenital Heart Disease (General)

• Etiology: Down syndrome (AV canal), Turner (coarctation), 22q11 (TOF), rubella (PDA, PS, ASD), maternal diabetes (TGA)
• Classification: Simple / Moderate / Complex; by hemodynamic type: L→R shunts, obstructive, R→L (cyanotic)
• Prevalence in adults: ASD (30-40%), VSD (15-20%), PDA (5-10%), Bicuspid AV (2% of population)

Q46 - PDA

• Classic murmur: "Machinery" (Gibson) - continuous crescendo-decrescendo at 1st-2nd left ICS
• Differential cyanosis: toes cyanotic, fingers normal (Eisenmenger PDA)
• Treatment: Ibuprofen/indomethacin (premature infants only); device closure (coil/Amplatzer) in adults; surgical ligation; contraindicated in Eisenmenger

Q47 - ASD

• Hallmark auscultation: Wide FIXED splitting of S2 + soft pulmonary ejection murmur
• ECG hallmark: Incomplete RBBB (rSR' in V1)
• Types: Secundum (70%, device closure), Primum (surgery needed - cleft MV), Sinus venosus (surgery needed - anomalous pulmonary veins)
• Treatment: Device closure (Amplatzer) for secundum ASD <3.5 cm; surgery for all others

Q48 - VSD

• Paradox: Louder murmur = smaller, more restrictive VSD (Roger's disease)
• Murmur: Holosystolic at lower left sternal border (4th ICS) ± thrill
• Classification: Perimembranous (70-80%), Muscular (15-20%), Outlet/supracristal (5-7%, Asian population, AR risk), Inlet (AV canal type)
• Treatment: Spontaneous closure common in small defects; device or surgical patch closure when Qp:Qs ≥2:1 or LV dilation

Q49 - Congenital Aortic Valve Stenosis

• Bicuspid AV: Most common adult CHD; accounts for 50% of surgical AS
• Classic triad: Angina (5-yr survival) → Syncope (3-yr) → Heart failure (2-yr) without AVR
• Parvus et tardus pulse + late-peaking ejection systolic murmur + absent A2 + S4
• Treatment: TAVR (preferred in intermediate/high surgical risk); SAVR (preferred <65 years); balloon valvuloplasty as bridge only

Q50 - Coarctation of the Aorta

• Classic signs: "3 sign" on CXR + rib notching (3rd-8th ribs) + brachial-femoral pulse delay
• Associations: Turner syndrome (35%), bicuspid AV (50% of coarctation patients), berry aneurysms (3-5%)
• Treatment: Balloon angioplasty + stent in adults; surgical resection/end-to-end anastomosis in infants; treat persistent hypertension with beta-blockers post-repair

Q51 - Tetralogy of Fallot

• 4 components: RVOTO + large non-restrictive VSD + overriding aorta + RVH (all from single embryologic defect - infundibular septum deviation)
• "Boot-shaped heart" on CXR + decreased pulmonary markings + right aortic arch (25%)
• No VSD murmur (non-restrictive VSD - no gradient); ejection murmur from RVOTO
• Tet spell management: Knee-chest position + O2 + morphine + phenylephrine + propranolol
• Long-term (repaired adults): Pulmonary regurgitation → RV dilation → indication for PVR (RVEDV >160 mL/m² on MRI); ICD for QRS >180 ms/VT risk