Cardiovascular Pathology MCQs

Question 1

A 63-year-old woman has sudden 'knife-like' chest pain radiating to the back, poorly controlled hypertension, and a widened mediastinum on CXR. CK is normal. Most likely diagnosis?

Accepted Answer

Aortic dissection — Tearing back pain + widened mediastinum + hypertension = classic aortic dissection. Normal CK rules out MI. ---

Question 2

A man is examined 4 days after a large transmural anterolateral MI with cardiogenic shock. Most likely microscopic finding?

Accepted Answer

Myofiber necrosis with neutrophils — At 3–4 days, necrosis persists with dominant neutrophils. Macrophages are just arriving. Peak risk for myocardial rupture. ---

Question 3

A 45-year-old woman has orthopnea, dysphagia, and a prior stroke. CXR shows near-normal LV but prominent left atrial border. Most likely condition?

Accepted Answer

Mitral valve stenosis — Left atrial enlargement causing dysphagia and stroke from mural thrombus, with small LV = mitral stenosis from prior rheumatic fever. ---

Question 4

A 16-year-old is stabbed in the left chest. BP barely obtainable, lungs clear, heart sounds barely audible. Most useful treatment?

Accepted Answer

Pericardiocentesis — Muffled heart sounds + hypotension + clear lungs after penetrating chest trauma = cardiac tamponade. Pericardiocentesis is immediately lifesaving. ---

Question 5

A 19-year-old with mid-systolic click, mitral insufficiency, aortic root dilation, and a dislocated lens dies suddenly. Ruptured chordae found at autopsy. Most likely gene mutation?

Accepted Answer

Fibrillin — Floppy mitral valve + aortic dilation + ectopia lentis = Marfan syndrome, caused by FBN1 mutations encoding fibrillin-1. ---

Question 6

A 72-year-old woman with no prior illness has three syncopal episodes then pulmonary edema. CXR shows LV prominence only. Cholesterol normal. Most likely diagnosis?

Accepted Answer

Calcific aortic stenosis — Elderly + no prior illness + syncope + LVH + pulmonary edema without systemic risk factors = senile calcific aortic stenosis. ---

Question 7

A 17-year-old short girl with absent puberty, webbed neck, upper extremity hypertension, diminished lower extremity pulses, and rib notching on CXR. Most likely cardiovascular abnormality?

Accepted Answer

Narrowing of the aorta past the ductus arteriosus — Turner syndrome + rib notching + upper/lower BP discrepancy = postductal coarctation of the aorta. ---

Question 8

A 65-year-old man with 20 years of uncontrolled diabetes has sudden severe abdominal pain, diminished lower-extremity pulses, and a pulsatile abdominal mass. CK normal. Most likely condition?

Accepted Answer

Atherosclerotic aortic aneurysm — Pulsatile abdominal mass + lower extremity hypoperfusion + long-standing diabetes = infrarenal atherosclerotic aortic aneurysm. ---

Question 9

A 49-year-old woman with poorly controlled atrial fibrillation dies after a stroke. Autopsy shows fused mitral leaflets, shortened chordae, and thrombus-filled enlarged left atrium. Most likely underlying cause?

Accepted Answer

Rheumatic heart disease — Fused mitral leaflets + shortened chordae + enlarged left atrium with mural thrombus = classic rheumatic mitral stenosis. ---

Question 10

A 23-year-old woman with a malar rash has a friction rub, a faint systolic murmur, small mitral vegetations on echo, and a very high anti-Smith antibody titer. Most likely diagnosis?

Accepted Answer

Systemic lupus erythematosus — Anti-Smith is highly specific for SLE. Libman-Sacks endocarditis (sterile vegetations) and fibrinous pericarditis (friction rub) are classic cardiac findings. ---

Question 11

A fetus at 18 weeks has a VSD, overriding aorta, and marked pulmonic atresia. If liveborn, what physical finding would most likely result?

Accepted Answer

Cyanosis — VSD + overriding aorta + pulmonic atresia = tetralogy of Fallot variant with right-to-left shunt, causing cyanosis from mixing of deoxygenated blood. ---

Question 12

A 50-year-old man has 3 hours of substernal chest pain, ST elevation in V1–V6, and pulmonary edema. Which lab finding is most likely?

Accepted Answer

Troponin of 32 ng/mL — Anterior STEMI causes myocyte necrosis releasing troponin within 3–4 hours. It remains elevated 10–14 days, making it the best early and sustained marker. ---

Question 13

A 44-year-old woman dies of a basal ganglia hemorrhage. She has LVH (550g heart), small scarred kidneys, and arterioles with concentric intimal thickening. Most likely condition?

Accepted Answer

Hypertensive emergency — LVH + CNS hemorrhage + small kidneys + hyperplastic arteriolosclerosis = malignant hypertension with multi-organ end-organ damage. ---

Question 14

A 24-year-old woman with rheumatic heart disease receives a porcine bioprosthesis. After 10 years it needs replacement. Most likely pathologic finding?

Accepted Answer

Calcification — Bioprosthetic valves avoid anticoagulation but undergo progressive calcification over 5–10 years, causing stenosis and requiring replacement. ---

Question 15

A healthy 25-year-old woman collapses suddenly. Echo shows global hypokinesis and reduced EF. Biopsy shows lymphocytic infiltrates with focal myocyte necrosis. Most likely infectious agent?

Accepted Answer

Coxsackie B virus — Lymphocytic myocarditis in a young person = viral etiology. Coxsackie B virus is the most common cause and can result in sudden cardiac death. ---

Question 16

A 22-year-old IV drug user has fever, hypotension, a loud systolic murmur, pulmonary edema, splinter hemorrhages, and Osler nodes. Most likely lab finding?

Accepted Answer

Positive blood culture for Pseudomonas aeruginosa — IV drug use is the key risk factor for infective endocarditis. Pseudomonas aeruginosa and Staph aureus are the most common organisms in this setting. ---

Question 17

A 2-year-old with failure to thrive has a large membranous VSD. What complication is she most likely to develop as an adult if untreated?

Accepted Answer

Pulmonary hypertension — Large left-to-right VSD causes chronic pulmonary overcirculation → pulmonary hypertension → eventual shunt reversal (Eisenmenger complex). ---

Question 18

A 53-year-old woman has progressive dyspnea, irregular pulse, enlarged right heart on CXR, thinned right ventricular wall, and reduced EF. Most likely etiology?

Accepted Answer

Gene mutation — Right ventricular thinning with fatty replacement in an autosomal dominant pattern = arrhythmogenic right ventricular cardiomyopathy (ARVC), caused by desmosomal gene mutations. ---

Question 19

A 26-year-old woman recovers fully from 2 weeks of fever, palpitations, dyspnea, elevated troponin, and mild cardiomegaly. No valvular vegetations. What lab finding best explains the etiology?

Accepted Answer

Echovirus serologic titer 1:160 — Self-limited myocarditis with full recovery in a young woman = viral myocarditis. Enteroviruses (echovirus, coxsackie) are the most common cause. ---

Question 20

A 45-year-old man with 5 years of polyarthritis develops biventricular heart failure. Glucose is 167 mg/dL. What additional lab finding is most likely?

Accepted Answer

Serum ferritin of 800 ng/mL — Dilated cardiomyopathy + diabetes + arthritis in a middle-aged man = hereditary hemochromatosis. Elevated ferritin reflects massive iron overload deposited in heart, pancreas, and joints. ---

Question 21

A 37-year-old man has a 10 cm right ventricular mass with hemorrhage and necrosis on CT, nearly filling the chest. Most likely neoplasm?

Accepted Answer

Angiosarcoma — A large hemorrhagic cardiac mass = malignancy. Angiosarcoma is the most common primary malignant cardiac tumor, typically arising in the right ventricle. ---

Question 22

A term baby girl is fine at birth but at 5 weeks develops pallor and a pansystolic murmur. Most likely congenital cardiac anomaly?

Accepted Answer

Ventricular septal defect — VSD is the most common congenital cardiac defect. Symptoms emerge weeks after birth when pulmonary resistance drops and left-to-right shunting increases. ---

Question 23

A 66-year-old man with no prior illness has progressive pulmonary congestion, a systolic ejection click, prominent left heart border, normal glucose and cholesterol, no CK elevation. Most likely underlying disease?

Accepted Answer

Calcified bicuspid aortic valve — A bicuspid aortic valve is present from birth but calcifies and causes stenosis in older adults. Ejection click + LVH + pulmonary edema without systemic risk factors is characteristic. ---

Question 24

A 35-year-old delirious man with fever 39.3°C, BP 70/palpable, a heart murmur, palpable spleen, and splinter hemorrhages is brought to the ED. Most likely lab finding?

Accepted Answer

Positive urine screen for opiates — The clinical picture is acute infective endocarditis. IV drug use is the major risk factor; positive opiate urine screen would confirm this predisposing condition. ---

Question 25

A 69-year-old woman has weight loss, painless jaundice, a pancreatic head mass, and liver/lung nodules. What cardiac abnormality is she most likely to develop?

Accepted Answer

Non-bacterial thrombotic endocarditis — Pancreatic cancer causes Trousseau syndrome — a paraneoplastic hypercoagulable state leading to marantic (non-bacterial thrombotic) endocarditis with sterile valvular vegetations. ---

Question 26

A 51-year-old woman has recurrent syncope, a 1.5 cm cystic parietal cortex lesion on brain MRI, no cardiac enlargement, and normal cholesterol. Most likely cardiac lesion?

Accepted Answer

Left atrial myxoma — Syncope + cerebral embolic infarct + no structural heart disease on CXR = left atrial myxoma, which can obstruct the mitral valve and embolize thrombus or tumor fragments. ---

Question 27

A 58-year-old man develops DVT postoperatively then has a left MCA stroke. CXR shows pulmonary hypertension. Troponin normal. Most likely lesion on echo?

Accepted Answer

Atrial septal defect — DVT → paradoxical embolism through an ASD → systemic arterial stroke. Pulmonary hypertension supports a long-standing shunt that has reversed (Eisenmenger complex). ---

Question 28

A 25-year-old man dies suddenly at a nightclub. Toxicology shows high cocaine levels. No gross cardiac pathology. Most likely histopathologic finding?

Accepted Answer

Contraction band necrosis — Cocaine causes catecholamine surge via reuptake blockade, producing intense vasospasm and ischemia, resulting in contraction band necrosis — the earliest visible histopathologic change. ---

Question 29

A 49-year-old man has confirmed anterior LAD thrombosis with elevated troponin. During the next 24 hours, what is the most likely complication?

Accepted Answer

Arrhythmia — The most common early complication of acute MI within the first 24–48 hours is arrhythmia, due to electrical instability of ischemic myocardium. ---

Question 30

A 60-year-old man had chest pain and 75% LAD stenosis. On day 4 he becomes hypotensive; pericardiocentesis yields 150 cc of bloody fluid. Most likely microscopic finding in his LV myocardium?

Accepted Answer

Necrosis with neutrophils and macrophages — At day 4, the infarct has both persistent neutrophils and arriving macrophages. This is the peak window for myocardial rupture, causing hemopericardium and tamponade. ---

Question 31

A 27-year-old man develops septic shock 3 days after tooth extraction. He has a split S2, a diastolic murmur, splinter hemorrhages, and splenomegaly. What cardiac condition predisposed him?

Accepted Answer

Atrial septal defect — A pre-existing ASD creates a structural abnormality that dental bacteremia can seed, causing infective endocarditis. The diastolic murmur and split S2 suggest this underlying defect. ---

Question 32

An epidemiologic study finds the 'bacon group' has more cardiovascular disease than the 'oat bran group.' What condition are they most likely to have?

Accepted Answer

Ventricular aneurysm — High-fat diet → atherosclerosis → MI. A ventricular aneurysm is a classic complication of transmural MI, forming when necrotic wall is replaced by thin, fibrotic, bulging scar. ---

Question 33

A 74-year-old man has 2 months of right-sided headaches, a palpable tender cord-like temporal lesion, and improves dramatically with corticosteroids. Most likely lab finding?

Accepted Answer

Erythrocyte sedimentation rate of 110 mm/hr — Temporal headache + tender temporal artery + giant cell granulomatous arteritis + corticosteroid response = temporal arteritis. ESR is dramatically elevated, far out of proportion to the localized inflammation. ---

Question 34

A 17-year-old girl has exercise-induced syncope, LVH and broad Q waves on EKG, and a 'ground glass' septum on echo. Most likely microscopic feature?

Accepted Answer

Myofiber disarray — Asymmetric septal hypertrophy + exercise syncope + ground glass appearance = hypertrophic cardiomyopathy. The hallmark microscopic finding is myofiber disarray with bizarre, whorled arrangements. ---

Question 35

A 78-year-old obese woman has 5 years of dyspnea, elevated CRP, LDL, and BNP, pulmonary edema, and segmental wall motion abnormalities on echo. Most likely cardiomyopathy?

Accepted Answer

Ischemic — Obesity + elevated CRP and LDL + segmental (not global) wall motion abnormalities = ischemic cardiomyopathy from coronary artery disease causing patchy infarction and dysfunction. ---

Question 36

A 51-year-old man has 3 hours of substernal chest pain with diaphoresis. EKG shows ST elevation. Elevated troponin confirmed. Most prominent histopathologic feature at this early time point?

Accepted Answer

Contraction band necrosis — Within the first few hours of MI, intracellular calcium overload causes hypercontraction of myofibers, producing contraction band necrosis — the earliest visible histopathologic change. ---

Question 37

A 58-year-old man has ascites, a cirrhotic liver on CT, and a globally enlarged heart on CXR. BP and HR are normal. Most likely cardiovascular condition?

Accepted Answer

Dilated cardiomyopathy — Cirrhosis + globally dilated heart without hypertension or ischemic features = alcoholic dilated cardiomyopathy. Alcohol is a direct myocardial toxin causing diffuse dilation. ---

Question 38

A 77-year-old man has progressive dyspnea, a diastolic murmur, a dilated thoracic aorta, and inflamed vasa vasora with medial elastic fiber disruption on histology. Most likely underlying condition?

Accepted Answer

Tertiary syphilis — Vasa vasora inflammation → medial destruction → thoracic aortic aneurysm + aortic regurgitation = tertiary (cardiovascular) syphilis, occurring decades after initial infection. ---

Question 39

A term baby girl develops respiratory distress and 80% O2 saturation at 12 hours of life. Pulses are weak. Most likely cardiac finding?

Accepted Answer

Hypoplastic left heart — Severe cyanosis and cardiovascular collapse shortly after birth = hypoplastic left heart syndrome. The underdeveloped left heart cannot generate adequate systemic output once the ductus closes. ---

Question 40

A 66-year-old man has a friction rub on chest auscultation, BUN of 100 mg/dL, and creatinine of 9.8 mg/dL. Most likely form of pericarditis?

Accepted Answer

Fibrinous — Severe uremia from renal failure triggers fibrin exudation onto pericardial surfaces, producing fibrinous pericarditis with a classic friction rub on auscultation. ---

Question 41

A 40-year-old man with proliferative glomerulonephritis has elevated ANA and anti-ds-DNA. Most likely cardiac abnormality?

Accepted Answer

Libman-Sacks endocarditis — Elevated ANA + anti-ds-DNA + glomerulonephritis = SLE. Libman-Sacks endocarditis — sterile small vegetations on the mitral and tricuspid valves — is the classic cardiac manifestation. ---

Question 42

A 53-year-old man has 3 months of malaise, distant heart sounds, a friction rub, and pericardiocentesis yields 10 mL of bloody fluid. Most likely condition?

Accepted Answer

Metastatic carcinoma — Bloody (hemorrhagic) pericardial effusion in a middle-aged man with constitutional symptoms = metastatic carcinoma invading the pericardium. Tuberculosis is the other classic cause. ---

Question 43

A 56-year-old man has untreated BP of 175/110 mmHg. If he remains untreated, what cardiac abnormality is he at greatest risk of developing?

Accepted Answer

Left ventricular hypertrophy — Chronic pressure overload from hypertension always produces left ventricular hypertrophy (concentric LVH) as the heart compensates for the increased afterload. This is the earliest and most universal cardiac consequence. ---

Question 44

A 48-year-old man with a brain anaplastic astrocytoma later develops splenic/renal pain, hematuria, and massive bilateral pulmonary emboli. Most likely cardiovascular lesion?

Accepted Answer

Mitral marantic vegetations — High-grade glioma + arterial and venous thromboembolic events = Trousseau syndrome (paraneoplastic hypercoagulability). Non-bacterial thrombotic endocarditis produces sterile mitral vegetations that embolize systemically. ---

Question 45

A 50-year-old man has bilateral leg swelling, dyspnea, basal crackles, and a prominent widened split S2. CXR shows enlarged right heart. Troponin normal. Most likely condition?

Accepted Answer

Pulmonary interstitial fibrosis — Right heart failure + loud prominent P2 (widened split S2) + normal troponin = cor pulmonale from pulmonary hypertension. Pulmonary interstitial fibrosis is a leading cause of secondary pulmonary hypertension.

Cardiovascular Pathology MCQs

Questions, Answers & Explanations