Cardiology Practice Questions

Q: Which chamber of the heart is enlarged first in a patient with mitral stenosis?

Left atrium. ***Left atrium*** - **Mitral stenosis** obstructs blood flow from the left atrium to the left ventricle, leading to a build-up of pressure in the left atrium [1]. - This chronic pressure overload causes the **left atrium to dilate and hypertrophy** in an attempt to pump blood through the narrowed valve [1]. *Left ventricle* - In **mitral stenosis**, the left ventricle typically receives a reduced volume of blood, leading to a **smaller, underfilled left ventricle**, rather than enlargement. - Its workload is decreased due to reduced preload, so it does not hypertrophy or dilate primarily. *Right ventricle* - **Right ventricular enlargement** can eventually occur in severe and chronic mitral stenosis due to **pulmonary hypertension** caused by back pressure from the left atrium, but it is not the *first* chamber to be affected [1], [2]. - Increased pressure in the pulmonary circulation increases the workload on the right ventricle, leading to hypertrophy and dilation over time [1], [2]. *Right atrium* - **Right atrial enlargement** is a consequence of chronic and severe pulmonary hypertension affecting the right ventricle, which then causes back pressure into the right atrium [1]. - This is a very late manifestation of mitral stenosis, occurring after significant involvement of the left atrium and pulmonary vasculature.

Q: Which is not seen in heart failure?

Oligemia. ***Oligemia*** - **Oligemia** refers to a reduced blood volume or total blood flow to a region, which is typically not observed in **heart failure**. - In **heart failure**, the body often experiences **fluid overload** and **pulmonary congestion**, leading to increased blood volume in the lungs, not reduced [1]. *Cardiomegaly* - **Cardiomegaly**, or an enlarged heart, is a common finding in **heart failure** as the heart muscle remodels and dilates to compensate for impaired pumping function [1], [3]. - This can be seen on a chest X-ray as an **increased cardiothoracic ratio** [1], [2]. *Kerley B lines* - **Kerley B lines** are thin, horizontal lines visible on a chest X-ray, typically found at the lung periphery. - They indicate **interstitial edema** due to increased pulmonary venous pressure, a characteristic sign of **pulmonary congestion** in **heart failure** [1]. *Kerley A Lines* - **Kerley A lines** are longer, less common lines seen radiating from the hila towards the upper lobes. - These lines represent **distended anastomotic channels** between pulmonary and systemic venous systems, also indicative of **pulmonary edema** and **heart failure** [1], [4].

Q: A person was brought to emergency department and was diagnosed with Supra ventricular tachycardia and suddenly he became unstable. What is the next line of management?

DC Cardioversion. ***DC Cardioversion*** - For **unstable supraventricular tachycardia (SVT)**, immediate **direct current (DC) cardioversion** is the definitive treatment to restore sinus rhythm. - Instability in SVT includes symptoms like hypotension, altered mental status, signs of shock, ischemic chest discomfort, or acute heart failure. *Intravenous ibutilide* - **Ibutilide** is an antiarrhythmic drug used for pharmacological cardioversion of recent-onset atrial fibrillation or flutter, but not typically for unstable SVT. - While it can convert certain supraventricular arrhythmias, it is generally reserved for **stable patients** and takes longer to act than immediate electrical cardioversion. *Intravenous Diltiazem* - **Diltiazem** is a calcium channel blocker used to control ventricular rate in **stable SVT**, atrial fibrillation, or flutter [1]. - It is contraindicated in unstable patients as it can further depress cardiac contractility and worsen hypotension [2]. *Intravenous Flecainide* - **Flecainide** is a class Ic antiarrhythmic drug used to maintain sinus rhythm in patients with supraventricular arrhythmias, including SVT. - It also takes time to act and is used in **stable patients** without structural heart disease, not in emergency unstable situations where immediate rhythm conversion is required.

Q: Which disease does not cause AV nodal block?

Cat scratch. ### Cat scratch - While cat scratch disease (caused by *Bartonella henselae*) can cause **lymphadenopathy** and other systemic symptoms, it is not typically associated with **AV nodal block** or direct cardiac involvement [1]. - The disease is usually self-limiting and rarely affects the electrical conduction system of the heart. ### Toxoplasmosis - **Toxoplasmosis**, caused by *Toxoplasma gondii*, can lead to **myocarditis** and **pericarditis**, which may disrupt the heart's electrical activity and cause AV nodal blocks, especially in immunocompromised individuals. - The parasite can directly infect cardiac muscle cells, leading to inflammation and conduction abnormalities. ### Chagas - **Chagas disease**, caused by *Trypanosoma cruzi*, is well-known for its propensity to cause **chronic Chagasic cardiomyopathy**, which frequently includes **AV nodal block** and other conduction defects [2]. - The parasite directly invades cardiac tissue, leading to fibrosis and destruction of the conduction system [2]. ### Lyme disease - **Lyme carditis**, a manifestation of Lyme disease caused by *Borrelia burgdorferi*, is a common cause of **AV nodal block**, often presenting with varying degrees of block. - The spirochete can directly infect the heart muscle, leading to inflammation and disruption of electrical pathways.

Q: A man who is chronic alcoholic will develop which type of cardiomyopathy?

Dilated cardiomyopathy. ***Dilated cardiomyopathy*** - Chronic alcohol abuse is a major cause of **dilated cardiomyopathy**, where the heart's pumping chambers (ventricles) become enlarged and weakened, leading to reduced cardiac output [1]. - This condition often called **alcoholic cardiomyopathy**, is characterized by **ventricular dilation** and **systolic dysfunction**. *Hypertrophic cardiomyopathy* - This condition involves thickening of the heart muscle, often genetic, and is not directly caused by **chronic alcoholism**. - While alcohol can worsen pre-existing heart conditions, it does not typically lead to primary **hypertrophic cardiomyopathy**. *Myocarditis* - **Myocarditis** is an inflammation of the heart muscle, usually caused by viral infections or autoimmune processes. - Although heavy alcohol use can weaken the immune system, it is not a direct cause of viral or primary inflammatory myocarditis. *Pericarditis* - **Pericarditis** is the inflammation of the pericardium, the sac surrounding the heart, most commonly due to viral infections or autoimmune conditions. - While alcohol abuse can have various systemic effects, it is not a recognized direct cause of **pericarditis**.

Q: Pulmonary Plethora is seen in -

TAPVC. ***TAPVC*** - **Total Anomalous Pulmonary Venous Connection (TAPVC)** leads to all pulmonary veins draining into the systemic circulation, causing a left-to-right shunt at the atrial level back into the right atrium. - This persistent shunting results in increased blood flow to the lungs, manifesting as **pulmonary plethora** on chest X-ray due to engorged pulmonary vessels [3]. *Tricuspid Atresia* - **Tricuspid atresia** results in an absence of the tricuspid valve, severely limiting blood flow from the right atrium to the right ventricle. - This condition typically leads to **pulmonary oligemia** (reduced blood flow to the lungs), not pulmonary plethora. *CoA* - **Coarctation of the aorta (CoA)** is a narrowing of the aorta, typically distal to the left subclavian artery [2]. - While it can lead to complications like heart failure, it generally does not directly cause **pulmonary plethora** unless there are associated shunts. *TOF* - **Tetralogy of Fallot (TOF)** is characterized by four defects: ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy [1]. - The most significant hemodynamic feature is **pulmonary stenosis**, which reduces blood flow to the lungs, leading to **pulmonary oligemia**, often described as a "boot-shaped" heart on X-ray [1].

Q: A 25-year-old female presented to ER unconscious. Her mother tells you about her having recurrent syncopal episodes. Her BP is 80/60 mm Hg and you order an ECG. Treatment is

DC shock. ***DC shock*** - The ECG shows a **wide complex tachycardia** with alternating morphology in the QRS complex, consistent with **Torsades de Pointes**. - Given the patient's **unconsciousness** and **hypotension (80/60 mmHg)**, she is hemodynamically unstable, making immediate **electrical cardioversion (DC shock)** the treatment of choice irrespective of the cause. *Catheter Ablation* - **Catheter ablation** is an invasive procedure used for definitive treatment of recurrent arrhythmias, often considered in patients who are *hemodynamically stable*. - It is not an acute, emergency treatment for an **unstable patient** in a life-threatening arrhythmia. *Adenosine* - **Adenosine** is primarily used to terminate **supraventricular tachycardias (SVTs)** and can be harmful in wide complex tachycardias, especially if due to ventricular tachycardia or Wolff-Parkinson-White syndrome. - Its use is contraindicated in wide complex tachycardias like Torsades de Pointes, and it would not be effective in an **unstable patient** with Torsades de Pointes. *Radiofrequency ablation* - **Radiofrequency ablation** is a type of catheter ablation, which ablates or destroys abnormal electrical pathways in the heart. - Similar to other ablative therapies, it is a **definitive treatment** for recurrent arrhythmias in *stable patients*, not an emergency measure for an unconscious, hypotensive patient with an acute arrhythmia.

Q: Stunning of myocardium without any acute coronary syndrome is:-

Takotsubo cardiomyopathy. ***Takotsubo cardiomyopathy*** - This condition involves **transient systolic dysfunction** of the left ventricle, often triggered by severe emotional or physical stress, mimicking a heart attack but without **coronary artery obstruction**. - The apical and mid-ventricular segments of the left ventricle become akinetic or hypocinetic, causing the heart to take on a shape resembling an octopus trap (**takotsubo**). *Restrictive cardiomyopathy* - This is a condition where the walls of the ventricles become **stiff** and **lose their flexibility**, preventing the heart from filling properly. - It is typically caused by conditions like **amyloidosis** or **sarcoidosis**, leading to impaired diastolic function, not transient stunning. *Subendocardial infarction* - This refers to a **heart attack** that affects only the **inner layer** of the heart muscle (**subendocardium**) due to reduced blood flow [2]. - It is a form of **acute coronary syndrome** where there is irreversible myocardial necrosis, unlike the temporary dysfunction in stunning [1]. *Transmural infarction* - This is a **severe form of heart attack** where the entire thickness of the heart muscle wall is affected, usually due to a **complete blockage of a coronary artery** [2]. - This also represents **acute coronary syndrome** with widespread myocardial necrosis, which is fundamentally different from a reversible stunning of the myocardium [1].

Q: A patient presents with palpitations, consciousness, fast pulse, and BP of 80/50 mmHg. After failed vagal maneuver and maximum dose of adenosine, what is the next step in management?

Cardioversion. ***Cardioversion*** - The patient presents with **symptomatic tachycardia** (palpitations, decreased consciousness, hypotension) refractory to **vagal maneuvers** and **adenosine**, indicating hemodynamic instability. - In such cases, **synchronized cardioversion** is the definitive treatment to restore sinus rhythm promptly and prevent further deterioration [1]. *Amiodarone* - **Amiodarone** is an antiarrhythmic drug used for stable wide complex tachycardia or as a second-line agent for unstable tachycardia after cardioversion. - It is not the immediate next step for an unstable patient who has failed adenosine, as its onset of action is slower than cardioversion [2]. *Repeat adenosine* - The question states that the patient has already received the **maximum dose of adenosine** and it has failed. - Administering more adenosine would be ineffective and delay definitive treatment for a hemodynamically unstable patient. *Defibrillation* - **Defibrillation** is used for **pulseless ventricular tachycardia/fibrillation** where there is no organized electrical activity [1]. - This patient has a pulse and an organized (though fast) rhythm, making synchronized cardioversion the appropriate electrical therapy.

Q: A patient presents with palpitations. On examination the patient was conscious, pulse was fast with BP of 80/50 mmHg. He was subjected to Vagal maneuver and was given intravenous adenosine. The rhythm remains refractory to maximum dose of adenosine. What is the next step in management of this patient?

Cardioversion. ***Cardioversion*** - As the patient is **hemodynamically unstable** (BP 80/50 mmHg) and has a **tachyarrhythmia** refractory to vagal maneuvers and maximal adenosine, **synchronized cardioversion** is the immediate next step. - This intervention provides a rapid and effective way to restore sinus rhythm in unstable supraventricular tachycardias (SVTs). *Repeat adenosine* - Adenosine has a very short half-life and its effects are transient; **repeated doses** beyond the maximal recommended dose are unlikely to be effective and may carry increased risk without benefit in a refractory case [2]. - The patient's **hemodynamic instability** necessitates a more definitive and immediate intervention than further pharmacotherapy. *Amiodarone* - While amiodarone is an **antiarrhythmic drug** used for tachyarrhythmias, it acts more slowly than cardioversion and is typically reserved for **hemodynamically stable** patients or after electrical cardioversion if arrhythmia recurs. - Given the patient's **hypotension**, immediate electrical cardioversion is prioritized over pharmacologic therapy that takes time to act. *Defibrillation* - Defibrillation is used for **pulseless ventricular tachyarrhythmias** (VT/VF) or cardiac arrest, which does not match the clinical scenario described as the patient has a pulse [1]. - This patient is in a **tachycardia with a pulse** and is hemodynamically unstable, requiring synchronized cardioversion rather than unsynchronized defibrillation.

Question 1

Which chamber of the heart is enlarged first in a patient with mitral stenosis?

Accepted Answer

Left atrium

Answer

Left ventricle

Answer

Right ventricle

Answer

Right atrium

Question 2

Which is not seen in heart failure?

Accepted Answer

Oligemia

Answer

Cardiomegaly

Answer

Kerley B lines

Answer

Kerley A Lines

Question 3

A person was brought to emergency department and was diagnosed with Supra ventricular tachycardia and suddenly he became unstable. What is the next line of management?

Accepted Answer

DC Cardioversion

Answer

Intravenous ibutilide

Answer

Intravenous Diltiazem

Answer

Intravenous Flecainide

Question 4

Which disease does not cause AV nodal block?

Accepted Answer

Cat scratch

Answer

Toxoplasmosis

Answer

Chagas

Answer

Lyme disease

Question 5

A man who is chronic alcoholic will develop which type of cardiomyopathy?

Accepted Answer

Dilated cardiomyopathy

Answer

Hypertrophic cardiomyopathy

Answer

Myocarditis

Answer

Pericarditis

Question 6

Pulmonary Plethora is seen in -

Accepted Answer

TAPVC

Answer

Tricuspid Atresia

Answer

CoA

Answer

TOF

Question 7

A 25-year-old female presented to ER unconscious. Her mother tells you about her having recurrent syncopal episodes. Her BP is 80/60 mm Hg and you order an ECG. Treatment is

Accepted Answer

DC shock

Answer

Cathether Ablation

Answer

Adenosine

Answer

Radiofrequency ablation

Question 8

Stunning of myocardium without any acute coronary syndrome is:-

Accepted Answer

Takotsubo cardiomyopathy

Answer

Restrictive cardiomyopathy

Answer

Subendocardial infarction

Answer

Transmural infarction

Question 9

A patient presents with palpitations, consciousness, fast pulse, and BP of 80/50 mmHg. After failed vagal maneuver and maximum dose of adenosine, what is the next step in management?

Accepted Answer

Cardioversion

Answer

Amiodarone

Answer

Repeat adenosine

Answer

Defibrillation

Question 10

A patient presents with palpitations. On examination the patient was conscious, pulse was fast with BP of 80/50 mmHg. He was subjected to Vagal maneuver and was given intravenous adenosine. The rhythm remains refractory to maximum dose of adenosine. What is the next step in management of this patient?

Accepted Answer

Cardioversion

Answer

Repeat adenosine

Answer

Amiodarone

Answer

Defibrillation

Cardiology — MCQs

Cardiology — MCQs

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