Cardiology Practice Questions

Q: Deep y descent in JVP is seen in all except:

Cardiac tamponade. **Cardiac tamponade** - In **cardiac tamponade**, the heart’s filling is severely restricted by fluid in the pericardial sac, leading to an **elevated right atrial pressure** that impedes venous return and results in **blunting or absence of the y descent** in the JVP [1]. - The elevated pericardial pressure prevents the right ventricle from expanding during early diastole, which is the physiological basis for the **normal y descent**. *RCM* - **Restrictive cardiomyopathy (RCM)** is characterized by **impaired ventricular filling** during diastole, causing a rapid fall in atrial pressure after tricuspid valve opening, resulting in a **prominent and deep y descent**. - The rapid early diastolic filling during the y descent is abruptly halted as the stiff ventricle is unable to further accommodate blood, leading to a rapid rise in ventricular pressure. *Constrictive pericarditis* - In **constrictive pericarditis**, the rigid pericardium encases the heart, severely **restricting diastolic filling** and causing a rapid early diastolic drop in right atrial pressure, hence a **prominent and deep y descent** [2]. - Despite the rapid initial fall, the y descent is often followed by a rapid rise in pressure (square root sign on ventricular pressure tracing) as the heart reaches the limits of its constrained filling. *Tricuspid regurgitation* - While **tricuspid regurgitation** primarily impacts the **c-v wave** due to backflow into the atrium during ventricular systole, it can also present with an **exaggerated y descent** if there is significant diastolic dysfunction or associated conditions like right heart failure. - However, the most classic JVP finding in severe tricuspid regurgitation is a prominent **regurgitant c-v wave**, not necessarily a deep y descent as a primary feature.

Q: What is indicated by an 'enlarged left atrium' on echocardiography?

Chronic mitral regurgitation. ***Chronic mitral regurgitation*** - Long-standing **mitral regurgitation** causes chronic volume overload in the left atrium, leading to its **dilatation** as a compensatory mechanism [1]. - This **atrial enlargement** is a key indicator of the chronicity and significant hemodynamic impact of the valve lesion. *Tricuspid stenosis* - **Tricuspid stenosis** primarily impacts the **right atrium**, causing its enlargement due to obstruction of blood flow into the right ventricle. - It does not directly affect the left atrium, although severe right-sided heart disease can sometimes indirectly influence left-sided filling. *Acute mitral regurgitation* - In **acute mitral regurgitation**, there is insufficient time for the left atrium to remodel and dilate significantly in response to the sudden volume overload [1]. - While left atrial pressure rises dramatically, the atrium itself typically appears **normal in size** or only mildly enlarged. *Pulmonary embolism* - A **pulmonary embolism** primarily affects the **right side of the heart**, leading to sudden increases in **pulmonary artery pressure** and right ventricular strain. - It does not directly cause left atrial enlargement, though severe acute right heart failure can impact left ventricular filling.

Q: Which condition is associated with 'prolonged PR interval' on an ECG?

First-degree AV block. ***First-degree AV block*** - First-degree AV block is defined by a consistent **prolongation of the PR interval** beyond 0.20 seconds, indicating delayed conduction through the AV node [1]. - While it is generally benign and asymptomatic, it reflects a **delay in electrical impulse transmission** from the atria to the ventricles [1], [3]. *Sinus bradycardia* - This condition is characterized by a **slow heart rate** (typically below 60 beats per minute) originating from the sinus node. - While the heart rate is slow, the **PR interval typically remains normal**, reflecting proper AV nodal conduction. *Second-degree AV block* - Second-degree AV block involves some **P waves not being conducted to the ventricules**, resulting in dropped QRS complexes [1]. - While PR intervals can be prolonged or progressively lengthen (Mobitz I), the key feature is **intermittent dropped beats**, not just blanket prolongation [1]. *Complete heart block* - Also known as third-degree AV block, this is a severe condition where **no atrial impulses are conducted to the ventricles**, leading to complete dissociation [2]. - The P waves and QRS complexes beat independently, meaning there is **no consistent PR interval** to measure as they are completely uncoupled [2].

Q: A 30 year old patient has right upper limb BP of 180/95 mm Hg and left upper limb BP of 130/90 mm Hg. He also has early diastolic murmur in right 2nd intercostal space. Which of the following would be LEAST likely associated with these findings?

Supravalvular aortic Stenosis. ***Supravalvular aortic Stenosis*** - **Supravalvular aortic stenosis** causes a pressure gradient above the aortic valve, leading to **left ventricular hypertrophy** and potentially differential blood pressures between the upper limbs, but typically with **higher pressures distally** from the stenosis. - The early diastolic murmur in the right 2nd intercostal space is more suggestive of **aortic regurgitation** [2], which is less directly caused by isolated supravalvular stenosis compared to other conditions listed. *Aortic dissection* - **Aortic dissection** can involve the great vessels originating from the aorta, leading to a significant **differential in blood pressure** between the upper limbs due to obstruction of flow to one arm [1]. - An early diastolic murmur, especially in the right 2nd intercostal space, can indicate **aortic regurgitation** [2] if the dissection extends to the aortic root. *Coarctation of aorta* - **Coarctation of the aorta** typically presents with **hypertension in the upper limbs** and lower or absent pulses in the lower limbs, but if the coarctation is pre-subclavian, it can cause a differential in arm blood pressures [1]. - A persistent **early diastolic murmur** can be heard in association with **bicuspid aortic valve**, which often co-exists with coarctation and can lead to aortic regurgitation [2]. *Takayasu arteritis* - **Takayasu arteritis** is a **vasculitis of large arteries**, commonly affecting the aorta and its main branches, which can lead to stenosis or occlusion of vessels supplying one arm, causing a **markedly different blood pressure** between the limbs. - Involvement of the aortic root can also lead to **aortic insufficiency**, manifesting as an early diastolic murmur [2].

Q: Patient shows ST depression, troponin rise 6h post-surgery. Next best step is:

Cardiology consult. ***Cardiology consult*** - A cardiology consult is the most appropriate next step given the presence of **ST depression** and a **troponin rise** post-surgery, indicating a likely myocardial infarction (MI). - This allows for prompt comprehensive evaluation, risk stratification, and initiation of specialized cardiac management by an expert. *12-lead ECG* - While a 12-lead ECG is an important diagnostic tool, the patient's existing **ST depression** suggests it has already been performed or noted. - A repeat ECG might be useful for tracking changes, but it doesn't replace the need for expert cardiac evaluation and management. *Echocardiogram* - An echocardiogram can assess **cardiac function**, wall motion abnormalities, and valvular issues, which are relevant in MI. - However, it's a diagnostic test that should be ordered and interpreted in the context of a broader cardiac workup, which a cardiologist can best coordinate. *Start heparin* - **Heparin** is an anticoagulant that may be part of the management for an MI, especially in certain types or for prevention of clot extension. - However, initiating anticoagulation should be done after a thorough assessment of the patient's cardiac status, bleeding risk post-surgery, and in consultation with cardiology, rather than as the immediate next best step.

Q: Which ECG change is most specific for acute pericarditis?

PR segment depression. ***PR segment depression*** - **PR segment depression** can be seen in approximately 80% of patients with acute pericarditis and is considered the **most specific ECG marker** [2]. - This finding is due to inflammation of the atria, causing altered atrial repolarization that manifests as depression of the **PR segment** in most leads (except aVR and V1, where it may be elevated). *T wave inversion* - **T wave inversion** typically occurs in later stages of pericarditis, after the resolution of ST-segment elevation [2]. - It is not specific to pericarditis and can be seen in various other conditions, including **myocardial ischemia** or infarction [1]. *Q waves* - The presence of **Q waves** usually indicates a transmural **myocardial infarction** and is not a feature of pericarditis [1]. - Pericarditis primarily affects the pericardium and typically does not cause myocardial necrosis that would result in pathological Q waves [1]. *ST segment elevation* - **ST segment elevation** is common in acute pericarditis, but it is typically generalized (diffuse) and concave upward, unlike the localized and convex upward ST elevation seen in **myocardial infarction** [1], [2]. - While present, its diffuse nature helps differentiate it from MI, but **PR depression** is a more specific marker [2].

Q: A 45-year-old female presents with dyspnea, orthopnea, and bilateral leg edema. Echo shows EF 35%. BNP 850 pg/mL. Which drug class has shown mortality benefit in this condition?

Beta blockers. ***Beta blockers*** - In **heart failure with reduced ejection fraction (HFrEF)**, beta blockers (e.g., carvedilol, metoprolol succinate, bisoprolol) significantly reduce **mortality** and hospitalizations [1]. - They work by blocking the adverse effects of **sympathetic nervous system activation** on the heart, improving cardiac remodeling and function over time. *Calcium channel blockers* - Non-dihydropyridine calcium channel blockers (e.g., verapamil, diltiazem) generally have **negative inotropic effects** and can worsen outcomes in HFrEF. - While some dihydropyridine calcium channel blockers (e.g., amlodipine) are considered safe, they do **not confer a mortality benefit** in this condition. *Alpha blockers* - Alpha blockers like prazosin are primarily used for **hypertension** and **benign prostatic hyperplasia**. - They have **not shown mortality benefit** in heart failure and may even cause symptomatic **hypotension**. *Nitrates* - Nitrates (e.g., isosorbide dinitrate, nitroglycerin) are effective **vasodilators** that reduce preload and afterload, alleviating symptoms like dyspnea [1]. - However, they do not consistently **reduce mortality** when used alone in HFrEF and are often combined with hydralazine for specific populations (e.g., African Americans).

Q: A 50-year-old patient presents with dyspnea, edema, and an elevated JVP. Which condition is most likely?

Right heart failure. ***Right heart failure*** - **Dyspnea**, **edema** (often peripheral), and an **elevated jugular venous pressure (JVP)** are classical signs of right heart failure due to systemic venous congestion [1]. - The inability of the right ventricle to pump blood efficiently leads to blood backing up in the systemic circulation [3]. *Left heart failure* - While it can cause dyspnea, left heart failure primarily leads to **pulmonary congestion** (e.g., crackles, orthopnea) and is less directly associated with prominent peripheral edema and elevated JVP as initial prominent symptoms [2]. - An elevated JVP and significant peripheral edema in left heart failure typically indicate progression to **biventricular failure** [1]. *Pneumonia* - Pneumonia typically presents with acute symptoms like **fever, cough with sputum, pleuritic chest pain**, and localized lung findings, rather than chronic dyspnea, edema, and elevated JVP. - It’s an **infectious lung condition**, not primarily a circulatory disorder causing systemic congestion. *Asthma* - Asthma is a **reversible obstructive airway disease** characterized by episodic **wheezing, cough, and shortness of breath** due to bronchospasm [4]. - It does not typically cause edema or an elevated JVP.

Q: Which condition is indicated by ST segment elevation in leads V1-V4?

Anterior myocardial infarction. ***Anterior myocardial infarction*** - **ST segment elevation** in leads **V1-V4** is indicative of an infarction in the **anterior wall** of the left ventricle [1]. - These leads correspond to the distribution of the **left anterior descending (LAD) coronary artery**, which supplies the anterior wall and septum [2]. *Posterior myocardial infarction* - This typically presents with **ST depression** in **V1-V4**, along with tall R waves and prominent T waves in the same leads, due to a reciprocal change. - Definitive diagnosis requires **posterior leads (V7-V9)**, which would show ST elevation. *Lateral myocardial infarction* - Characterized by **ST elevation** in leads **I, aVL, V5, and V6**, reflecting ischemia in the lateral wall of the left ventricle [1]. - These leads are supplied by the **circumflex artery** or a diagonal branch of the LAD. *Inferior myocardial infarction* - Identified by **ST elevation** in leads **II, III, and aVF**, indicating involvement of the inferior wall [1]. - This is typically caused by occlusion of the **right coronary artery (RCA)** or a dominant circumflex artery.

Q: Which finding on echocardiography suggests 'constrictive pericarditis'?

Pericardial thickening and septal bounce. ***Pericardial thickening and septal bounce*** - **Pericardial thickening** is a direct anatomical feature of constrictive pericarditis, indicating the fibrotic and inflamed state of the pericardium. - **Septal bounce**, or interventricular septal motion variation with respiration, is a highly specific sign of constriction, due to exaggerated ventricular interdependence. *Increased wall thickness* - This finding is more characteristic of **hypertrophic cardiomyopathy** or **hypertensive heart disease**, where the myocardial muscle itself thickens. - While it can impair diastolic function, it doesn't indicate a primary pericardial issue. *Global hypokinesis* - **Global hypokinesis** refers to reduced overall contractility of the heart muscle, typically seen in conditions like **dilated cardiomyopathy** or significant **ischemic heart disease**. - This indicates systolic dysfunction, whereas constrictive pericarditis primarily affects diastolic filling. *Pericardial effusion* - A **pericardial effusion** is an accumulation of fluid around the heart, which can cause **cardiac tamponade** if severe. - While effusions can sometimes precede or coexist with constrictive pericarditis, the fluid itself is not the hallmark of constriction, which is defined by a thickened, rigid pericardium.

Question 1

Deep y descent in JVP is seen in all except:

Accepted Answer

Cardiac tamponade

Answer

RCM

Answer

Constrictive pericarditis

Answer

Tricuspid regurgitation

Question 2

What is indicated by an 'enlarged left atrium' on echocardiography?

Accepted Answer

Chronic mitral regurgitation

Answer

Tricuspid stenosis

Answer

Acute mitral regurgitation

Answer

Pulmonary embolism

Question 3

Which condition is associated with 'prolonged PR interval' on an ECG?

Accepted Answer

First-degree AV block

Answer

Sinus bradycardia

Answer

Second-degree AV block

Answer

Complete heart block

Question 4

A 30 year old patient has right upper limb BP of 180/95 mm Hg and left upper limb BP of 130/90 mm Hg. He also has early diastolic murmur in right 2nd intercostal space. Which of the following would be LEAST likely associated with these findings?

Accepted Answer

Supravalvular aortic Stenosis

Answer

Aortic dissection

Answer

Coarctation of aorta

Answer

Takayasu arteritis

Question 5

Patient shows ST depression, troponin rise 6h post-surgery. Next best step is:

Accepted Answer

Cardiology consult

Answer

12-lead ECG

Answer

Echocardiogram

Answer

Start heparin

Question 6

Which ECG change is most specific for acute pericarditis?

Accepted Answer

PR segment depression

Answer

T wave inversion

Answer

Q waves

Answer

ST segment elevation

Question 7

A 45-year-old female presents with dyspnea, orthopnea, and bilateral leg edema. Echo shows EF 35%. BNP 850 pg/mL. Which drug class has shown mortality benefit in this condition?

Accepted Answer

Beta blockers

Answer

Calcium channel blockers

Answer

Alpha blockers

Answer

Nitrates

Question 8

A 50-year-old patient presents with dyspnea, edema, and an elevated JVP. Which condition is most likely?

Accepted Answer

Right heart failure

Answer

Left heart failure

Answer

Pneumonia

Answer

Asthma

Question 9

Which condition is indicated by ST segment elevation in leads V1-V4?

Accepted Answer

Anterior myocardial infarction

Answer

Posterior myocardial infarction

Answer

Lateral myocardial infarction

Answer

Inferior myocardial infarction

Question 10

Which finding on echocardiography suggests 'constrictive pericarditis'?

Accepted Answer

Pericardial thickening and septal bounce

Answer

Increased wall thickness

Answer

Global hypokinesis

Answer

Pericardial effusion

Cardiology — MCQs

Cardiology — MCQs

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