Medical Surgery – Cardiac
Q1. A 68-year-old male with stable angina and a 70% stenosis of the left anterior descending
(LAD) artery, 60% stenosis of the circumflex, and a 50% stenosis of the right coronary artery
(RCA) has an ejection fraction (EF) of 55%. He is asymptomatic at rest but becomes dyspneic
on walking 2 blocks. His comorbidities include diabetes and hypertension. According to the
2021 ACC/AHA revascularization guidelines, what is the most appropriate management?
A) Optimal medical therapy (OMT) alone
B) Percutaneous coronary intervention (PCI) with drug-eluting stents
C) Coronary artery bypass grafting (CABG)
D) PCI for LAD and OMT for others
E) CABG with concomitant mitral valve repair
Detailed Answer:
Correct Answer: C
This patient has multivessel coronary disease (2–3 vessels) with diabetes and significant LAD
stenosis. The SYNTAX score would likely be intermediate to high. The 2021 ACC/AHA
guidelines recommend CABG over PCI for patients with multivessel disease and diabetes to
improve survival and reduce repeat revascularization. CABG is especially beneficial when the
LAD is involved. PCI (B) is preferred for single-vessel or low-risk disease. OMT alone (A) is not
indicated with significant symptoms and anatomy. A mitral valve repair (E) is not needed
without significant mitral regurgitation.
Q2. A 72-year-old patient with a history of prior PCI (drug-eluting stent to LAD 3 years ago)
now presents with recurrent angina. Coronary angiography shows in-stent restenosis of the
LAD and a new 80% stenosis of the RCA. The left internal mammary artery (LIMA) is patent
and suitable. The most appropriate surgical strategy is:
A) PCI to the in-stent restenosis and OMT for RCA
B) Redo PCI with drug-eluting balloon for LAD and stent to RCA
C) CABG with LIMA to LAD and saphenous vein graft (SVG) to RCA
D) CABG with bilateral internal mammary arteries (BIMA)
E) Medical management with intensified anti-anginals
Detailed Answer:
Correct Answer: C
Redo revascularization with a patent LIMA is favorable. The LIMA can be used to bypass the
LAD (even if previously stented) and a SVG can be used for the RCA. Bilateral IMA (D) is an
option but increases sternal wound risk, especially in an older patient. PCI (A/B) is less
,durable in the setting of restenosis and new multivessel disease. Medical management (E) is
not appropriate for symptomatic multivessel disease.
Q3. A 60-year-old female with an EF of 25% and severe left main coronary artery disease
(>50% stenosis) is scheduled for CABG. She is in New York Heart Association (NYHA) class III
heart failure. Which of the following preoperative interventions has been shown to improve
outcomes in this high-risk population?
A) Intra-aortic balloon pump (IABP) placement preoperatively
B) Preoperative optimization with milrinone
C) Preoperative coronary CT angiography
D) Preoperative revascularization of non-culprit vessels
E) Preoperative left ventricular assist device (LVAD)
Detailed Answer:
Correct Answer: A
Preoperative IABP placement in high-risk patients (left main disease, low EF, or unstable
angina) has been shown to reduce operative mortality and improve hemodynamic support
during induction of anesthesia. Milrinone (B) is not recommended preoperatively. CT
angiography (C) is not therapeutic. Revascularization of non-culprits (D) is done
intraoperatively. LVAD (E) is for end-stage failure as a bridge or destination therapy, not pre-
CABG.
Q4. A patient with a history of prior coronary artery bypass grafting (CABG) 10 years ago with
LIMA to LAD and SVG to RCA now presents with an acute coronary syndrome. Angiography
reveals a patent LIMA-LAD, occluded SVG-RCA, and a new 90% stenosis of the circumflex
artery. The most appropriate management is:
A) Redo CABG with a new SVG to circumflex
B) PCI to the SVG-RCA
C) PCI to the native circumflex artery
D) Medical management only
E) Redo CABG with BIMA and SVG
Detailed Answer:
Correct Answer: C
In a patient with a patent LIMA-LAD, new disease in the native circumflex is best managed
with PCI to the native vessel, as it is less invasive than redo CABG. PCI to the occluded SVG (B)
carries high risk of distal embolization and no-reflow. Redo CABG (A/E) is associated with
,significantly higher morbidity and mortality and should be reserved for patients with no
option for PCI or with diffuse disease.
Q5. Which of the following preoperative laboratory values is the strongest independent
predictor of increased mortality and morbidity after CABG?
A) Serum creatinine >1.5 mg/dL
B) Hemoglobin A1c >8%
C) Preoperative albumin <3.0 g/dL
D) Brain natriuretic peptide (BNP) >100 pg/mL
E) Platelet count <100,000/µL
Detailed Answer:
Correct Answer: C
Preoperative hypoalbuminemia (<3.0 g/dL) is a powerful independent predictor of
postoperative mortality, infection, wound dehiscence, and prolonged ICU stay. Elevated
creatinine (A) is also a predictor but less strong than albumin. Elevated BNP (D) is a marker of
heart failure but not as robust as albumin. HbA1c (B) and platelets (E) are important but not
the strongest.
Q6. A 65-year-old patient with a history of heparin-induced thrombocytopenia (HIT) requires
urgent CABG. The appropriate intraoperative anticoagulant is:
A) Unfractionated heparin
B) Low-molecular-weight heparin (LMWH)
C) Bivalirudin
D) Argatroban
E) Fondaparinux
Detailed Answer:
Correct Answer: C
Bivalirudin is a direct thrombin inhibitor approved for use in patients with HIT undergoing
cardiac surgery. Argatroban (D) is also used but is cleared hepatically and is less commonly
used intraoperatively due to lack of a reversal agent. Heparin (A) is absolutely
contraindicated. LMWH (B) has cross-reactivity with HIT antibodies. Fondaparinux (E) is a
factor Xa inhibitor but not routinely used for cardiopulmonary bypass.
, Q7. A patient is scheduled for an on-pump CABG. He is currently on aspirin 81 mg daily,
clopidogrel 75 mg daily, and atorvastatin 80 mg daily. Which medication should be continued
through the perioperative period?
A) Aspirin
B) Clopidogrel
C) Atorvastatin
D) Aspirin and clopidogrel
E) All three should be stopped
Detailed Answer:
Correct Answer: C
Atorvastatin (and all statins) should be continued perioperatively as they reduce the risk of
postoperative atrial fibrillation, myocardial injury, and stroke. Aspirin is often continued for
CABG (Class I recommendation) but is sometimes held 5 days before. Clopidogrel should be
stopped 5 days before surgery to reduce bleeding. Therefore, statin is the one that should
definitely be continued.
Q8. A 70-year-old patient with severe carotid stenosis (80% right and 60% left) and
symptomatic left main coronary disease is scheduled for CABG. The most appropriate strategy
for carotid revascularization is:
A) Staged carotid endarterectomy (CEA) followed by CABG
B) Staged CABG followed by CEA
C) Combined CEA and CABG in the same operation
D) Medical management of carotid disease with antiplatelets
E) No intervention; proceed with CABG alone
Detailed Answer:
Correct Answer: A
For patients with symptomatic carotid stenosis and severe coronary disease, the standard
approach is a staged procedure with CEA first (to reduce stroke risk during CABG) followed by
CABG after a period of hemodynamic stability. Combined CEA/CABG (C) has higher stroke and
death rates. CABG first (B) risks stroke during bypass. Medical management (D/E) is
insufficient for symptomatic stenosis.
Q9. A patient is being evaluated for CABG. His Society of Thoracic Surgeons (STS) predicted
risk of mortality (PROM) is 8%. The most appropriate strategy to reduce perioperative risk is:
A) Off-pump CABG (OPCAB)
Q1. A 68-year-old male with stable angina and a 70% stenosis of the left anterior descending
(LAD) artery, 60% stenosis of the circumflex, and a 50% stenosis of the right coronary artery
(RCA) has an ejection fraction (EF) of 55%. He is asymptomatic at rest but becomes dyspneic
on walking 2 blocks. His comorbidities include diabetes and hypertension. According to the
2021 ACC/AHA revascularization guidelines, what is the most appropriate management?
A) Optimal medical therapy (OMT) alone
B) Percutaneous coronary intervention (PCI) with drug-eluting stents
C) Coronary artery bypass grafting (CABG)
D) PCI for LAD and OMT for others
E) CABG with concomitant mitral valve repair
Detailed Answer:
Correct Answer: C
This patient has multivessel coronary disease (2–3 vessels) with diabetes and significant LAD
stenosis. The SYNTAX score would likely be intermediate to high. The 2021 ACC/AHA
guidelines recommend CABG over PCI for patients with multivessel disease and diabetes to
improve survival and reduce repeat revascularization. CABG is especially beneficial when the
LAD is involved. PCI (B) is preferred for single-vessel or low-risk disease. OMT alone (A) is not
indicated with significant symptoms and anatomy. A mitral valve repair (E) is not needed
without significant mitral regurgitation.
Q2. A 72-year-old patient with a history of prior PCI (drug-eluting stent to LAD 3 years ago)
now presents with recurrent angina. Coronary angiography shows in-stent restenosis of the
LAD and a new 80% stenosis of the RCA. The left internal mammary artery (LIMA) is patent
and suitable. The most appropriate surgical strategy is:
A) PCI to the in-stent restenosis and OMT for RCA
B) Redo PCI with drug-eluting balloon for LAD and stent to RCA
C) CABG with LIMA to LAD and saphenous vein graft (SVG) to RCA
D) CABG with bilateral internal mammary arteries (BIMA)
E) Medical management with intensified anti-anginals
Detailed Answer:
Correct Answer: C
Redo revascularization with a patent LIMA is favorable. The LIMA can be used to bypass the
LAD (even if previously stented) and a SVG can be used for the RCA. Bilateral IMA (D) is an
option but increases sternal wound risk, especially in an older patient. PCI (A/B) is less
,durable in the setting of restenosis and new multivessel disease. Medical management (E) is
not appropriate for symptomatic multivessel disease.
Q3. A 60-year-old female with an EF of 25% and severe left main coronary artery disease
(>50% stenosis) is scheduled for CABG. She is in New York Heart Association (NYHA) class III
heart failure. Which of the following preoperative interventions has been shown to improve
outcomes in this high-risk population?
A) Intra-aortic balloon pump (IABP) placement preoperatively
B) Preoperative optimization with milrinone
C) Preoperative coronary CT angiography
D) Preoperative revascularization of non-culprit vessels
E) Preoperative left ventricular assist device (LVAD)
Detailed Answer:
Correct Answer: A
Preoperative IABP placement in high-risk patients (left main disease, low EF, or unstable
angina) has been shown to reduce operative mortality and improve hemodynamic support
during induction of anesthesia. Milrinone (B) is not recommended preoperatively. CT
angiography (C) is not therapeutic. Revascularization of non-culprits (D) is done
intraoperatively. LVAD (E) is for end-stage failure as a bridge or destination therapy, not pre-
CABG.
Q4. A patient with a history of prior coronary artery bypass grafting (CABG) 10 years ago with
LIMA to LAD and SVG to RCA now presents with an acute coronary syndrome. Angiography
reveals a patent LIMA-LAD, occluded SVG-RCA, and a new 90% stenosis of the circumflex
artery. The most appropriate management is:
A) Redo CABG with a new SVG to circumflex
B) PCI to the SVG-RCA
C) PCI to the native circumflex artery
D) Medical management only
E) Redo CABG with BIMA and SVG
Detailed Answer:
Correct Answer: C
In a patient with a patent LIMA-LAD, new disease in the native circumflex is best managed
with PCI to the native vessel, as it is less invasive than redo CABG. PCI to the occluded SVG (B)
carries high risk of distal embolization and no-reflow. Redo CABG (A/E) is associated with
,significantly higher morbidity and mortality and should be reserved for patients with no
option for PCI or with diffuse disease.
Q5. Which of the following preoperative laboratory values is the strongest independent
predictor of increased mortality and morbidity after CABG?
A) Serum creatinine >1.5 mg/dL
B) Hemoglobin A1c >8%
C) Preoperative albumin <3.0 g/dL
D) Brain natriuretic peptide (BNP) >100 pg/mL
E) Platelet count <100,000/µL
Detailed Answer:
Correct Answer: C
Preoperative hypoalbuminemia (<3.0 g/dL) is a powerful independent predictor of
postoperative mortality, infection, wound dehiscence, and prolonged ICU stay. Elevated
creatinine (A) is also a predictor but less strong than albumin. Elevated BNP (D) is a marker of
heart failure but not as robust as albumin. HbA1c (B) and platelets (E) are important but not
the strongest.
Q6. A 65-year-old patient with a history of heparin-induced thrombocytopenia (HIT) requires
urgent CABG. The appropriate intraoperative anticoagulant is:
A) Unfractionated heparin
B) Low-molecular-weight heparin (LMWH)
C) Bivalirudin
D) Argatroban
E) Fondaparinux
Detailed Answer:
Correct Answer: C
Bivalirudin is a direct thrombin inhibitor approved for use in patients with HIT undergoing
cardiac surgery. Argatroban (D) is also used but is cleared hepatically and is less commonly
used intraoperatively due to lack of a reversal agent. Heparin (A) is absolutely
contraindicated. LMWH (B) has cross-reactivity with HIT antibodies. Fondaparinux (E) is a
factor Xa inhibitor but not routinely used for cardiopulmonary bypass.
, Q7. A patient is scheduled for an on-pump CABG. He is currently on aspirin 81 mg daily,
clopidogrel 75 mg daily, and atorvastatin 80 mg daily. Which medication should be continued
through the perioperative period?
A) Aspirin
B) Clopidogrel
C) Atorvastatin
D) Aspirin and clopidogrel
E) All three should be stopped
Detailed Answer:
Correct Answer: C
Atorvastatin (and all statins) should be continued perioperatively as they reduce the risk of
postoperative atrial fibrillation, myocardial injury, and stroke. Aspirin is often continued for
CABG (Class I recommendation) but is sometimes held 5 days before. Clopidogrel should be
stopped 5 days before surgery to reduce bleeding. Therefore, statin is the one that should
definitely be continued.
Q8. A 70-year-old patient with severe carotid stenosis (80% right and 60% left) and
symptomatic left main coronary disease is scheduled for CABG. The most appropriate strategy
for carotid revascularization is:
A) Staged carotid endarterectomy (CEA) followed by CABG
B) Staged CABG followed by CEA
C) Combined CEA and CABG in the same operation
D) Medical management of carotid disease with antiplatelets
E) No intervention; proceed with CABG alone
Detailed Answer:
Correct Answer: A
For patients with symptomatic carotid stenosis and severe coronary disease, the standard
approach is a staged procedure with CEA first (to reduce stroke risk during CABG) followed by
CABG after a period of hemodynamic stability. Combined CEA/CABG (C) has higher stroke and
death rates. CABG first (B) risks stroke during bypass. Medical management (D/E) is
insufficient for symptomatic stenosis.
Q9. A patient is being evaluated for CABG. His Society of Thoracic Surgeons (STS) predicted
risk of mortality (PROM) is 8%. The most appropriate strategy to reduce perioperative risk is:
A) Off-pump CABG (OPCAB)
