Acquired Heart Disease Questions - Set 2¶
Question 1¶
A 15-year-old with MIS-C has LV dysfunction (EF 35%) and coronary dilation (LAD Z-score 3.5). What is the recommended initial treatment?
A) IVIG alone B) IVIG + methylprednisolone C) Methylprednisolone alone D) Tocilizumab first-line E) Anakinra first-line
Answer
**Correct Answer: B** MIS-C initial treatment = **IVIG + steroids** together: - 2021 ACR guidelines - Better outcomes than either alone (BATS, OVERCOMING studies) - Refractory: biologics (anakinra, infliximab) **Board Pearl:** MIS-C = IVIG + steroids together first-lineQuestion 2¶
After MIS-C with coronary involvement, what is the recommended follow-up for coronary assessment?
A) Echo at 2 weeks only B) Echo at 2 weeks and 6 weeks C) Echo at 2 weeks, 6 weeks, and 6 months D) No follow-up needed if initial coronaries normal E) Annual echocardiograms lifelong
Answer
**Correct Answer: C** MIS-C coronary follow-up: - **2 weeks**: Early assessment - **6 weeks**: Intermediate - **6 months** (or longer if abnormal): Late follow-up Similar to Kawasaki disease follow-up protocol. **Board Pearl:** MIS-C follow-up = 2 weeks, 6 weeks, 6 months echo (similar to KD)Question 3¶
What is the most sensitive imaging modality for diagnosing myocarditis?
A) Echocardiography B) Chest X-ray C) Cardiac MRI D) CT coronary angiography E) Nuclear perfusion imaging
Answer
**Correct Answer: C** **Cardiac MRI** (Lake Louise criteria): - T2 for edema - Late gadolinium enhancement for fibrosis - T1 mapping - Sensitivity ~85-90% for active myocarditis **Board Pearl:** CMR = gold standard for myocarditis diagnosis (Lake Louise criteria)Question 4¶
A patient with rheumatic heart disease has severe mitral stenosis and atrial fibrillation. What is the INR target for anticoagulation?
A) 1.5-2.0 B) 2.0-2.5 C) 2.0-3.0 D) 2.5-3.5 E) 3.0-4.0
Answer
**Correct Answer: C** Rheumatic MS + AF = **INR 2.0-3.0**: - High thromboembolic risk - Warfarin preferred over DOACs - Some guidelines suggest 2.5-3.5 if prior embolism **Board Pearl:** RHD mitral stenosis + AF = warfarin INR 2.0-3.0Question 5¶
What is the mechanism of carditis in acute rheumatic fever?
A) Direct streptococcal infection of the heart B) Molecular mimicry between strep antigens and cardiac tissue C) Toxin-mediated damage D) Type 1 hypersensitivity reaction E) Autoantibody-mediated destruction
Answer
**Correct Answer: B** ARF carditis = **molecular mimicry**: - Strep M protein resembles cardiac myosin, laminin - Cross-reactive antibodies attack cardiac tissue - Delayed immune response (2-4 weeks after pharyngitis) - Explains pancarditis pattern **Board Pearl:** ARF = molecular mimicry; antibodies cross-react with cardiac antigensQuestion 6¶
An 8-year-old with Kawasaki disease received IVIG but has persistent fever at 48 hours. What is the next step?
A) Observe for 24 more hours B) Second dose of IVIG 2g/kg C) Start infliximab D) Switch to plasmapheresis E) Start cyclosporine
Answer
**Correct Answer: B** IVIG-resistant KD (fever >36h post-IVIG): - **Second IVIG 2g/kg** is first-line - If still refractory: infliximab, cyclosporine, or steroids (if not already given) **Board Pearl:** IVIG-resistant KD = second IVIG dose first; infliximab if still refractoryQuestion 7¶
Which statin is FDA-approved for use in children with familial hypercholesterolemia?
A) Atorvastatin B) Rosuvastatin C) Simvastatin D) Pravastatin E) All of the above except rosuvastatin
Answer
**Correct Answer: D** **Pravastatin** approved age 8+: - Also: atorvastatin, rosuvastatin, fluvastatin, simvastatin - Ezetimibe approved for adjunctive therapy - PCSK9 inhibitors in severe cases **Board Pearl:** Multiple statins FDA-approved for pediatric FH (age 8-10+)Question 8¶
A child with infective endocarditis has vegetation on the aortic valve with severe AR and heart failure. What is the management?
A) IV antibiotics for 6 weeks, then reassess B) Continue antibiotics, add heart failure medications C) Urgent surgical intervention D) Percutaneous valve intervention E) Cardiac transplant evaluation
Answer
**Correct Answer: C** **Urgent surgery** for IE with: - Hemodynamic compromise/heart failure - Persistent infection despite antibiotics - Large mobile vegetation (>10mm) - Embolic events - Abscess/fistula formation **Board Pearl:** IE + heart failure = urgent surgical indicationQuestion 9¶
What is the most common organism causing infective endocarditis in children with native valves?
A) Streptococcus viridans B) Staphylococcus aureus C) Coagulase-negative staphylococcus D) Enterococcus E) HACEK organisms
Answer
**Correct Answer: B** **Staphylococcus aureus** now most common: - Especially with central lines, prosthetic material - Strep viridans still common with dental source - More virulent than strep **Board Pearl:** S. aureus = most common IE pathogen in children nowQuestion 10¶
Which pericarditis etiology requires more than NSAID + colchicine for treatment?
A) Viral pericarditis B) Post-cardiac surgery pericarditis C) Purulent (bacterial) pericarditis D) Idiopathic pericarditis E) Drug-induced pericarditis