Cardiology Practice Questions

Q: A 62-year-old man with type 2 diabetes and a history of myocardial infarction is being treated for heart failure with reduced ejection fraction (HFrEF). According to the latest guidelines, which of the following medications should be added to optimize his treatment?

Sodium-glucose cotransporter-2 (SGLT2) inhibitor. ***Sodium-glucose cotransporter-2 (SGLT2) inhibitor*** * **SGLT2 inhibitors** are now recommended as a foundational therapy for HFrEF, regardless of diabetes status, due to their proven benefits in reducing **cardiovascular death** and **heart failure hospitalizations**. * In this patient with **type 2 diabetes** and **HFrEF**, an SGLT2 inhibitor would provide both glycemic control and significant cardiovascular protection. * *Sacubitril/valsartan* * **Sacubitril/valsartan** is a neprilysin inhibitor/angiotensin receptor blocker (ARNI) that is a cornerstone of HFrEF treatment, often replacing an **ACE inhibitor** or **ARB** [1]. * However, the question asks which medication *should be added* to *optimize* treatment, implying other foundational therapies might already be in place, and SGLT2 inhibitors offer an additional, distinct benefit. * *Ivabradine* * **Ivabradine** is indicated for HFrEF patients who are in **sinus rhythm** with a resting heart rate ≥ 70 bpm despite being on maximally tolerated doses of **beta-blockers**, to further reduce hospitalizations [1]. * The question does not provide information about his sinus rhythm or heart rate, or current beta-blocker status. * *Digoxin* * **Digoxin** may be considered in patients with HFrEF to reduce **heart failure hospitalizations**, particularly in those with **atrial fibrillation** or persistent symptoms despite optimal guideline-directed medical therapy [1]. * It does not improve survival in HFrEF and is generally reserved for patients who remain symptomatic after other foundational therapies.

Q: Identify the primary drug used for pharmacological stress testing in echocardiography.

Dobutamine. ***Dobutamine*** - **Dobutamine** is a synthetic catecholamine that stimulates beta-1 adrenergic receptors, increasing **myocardial contractility** and **heart rate**, thereby mimicking the effects of exercise. - It is the most commonly used pharmacological agent for **stress echocardiography** to evaluate for inducible **myocardial ischemia**. *Adenosine* - **Adenosine** is primarily used for **pharmacological stress testing** in **myocardial perfusion imaging (MPI)**, not typically for echocardiography. - It causes **coronary vasodilation**, leading to increased blood flow in healthy vessels, while stenotic vessels cannot dilate, highlighting relative perfusion differences. *Atropine* - **Atropine** is an **anticholinergic drug** used to increase heart rate when the target heart rate is not achieved with dobutamine alone during stress echocardiography. - It is an **adjunct** or **secondary agent**, not the primary drug, for inducing stress. *Diltiazem* - **Diltiazem** is a **calcium channel blocker** used to treat **hypertension** and **angina**, typically decreasing heart rate and myocardial oxygen demand. - It is an **anti-ischemic drug** and would counteract the purpose of a **stress test**, which is to induce and unmask ischemia.

Q: A 72-year-old female presents with dyspnea on exertion and an ejection systolic murmur best heard at the right upper sternal border. Echocardiography reveals a calcified aortic valve with restricted movement. What is the most likely diagnosis?

Aortic stenosis. ***Aortic stenosis*** - The classic presentation of **dyspnea on exertion** and an **ejection systolic murmur** at the **right upper sternal border** in an elderly patient is highly suggestive of aortic stenosis [1]. - **Echocardiography demonstrating a calcified aortic valve with restricted movement** definitively confirms the diagnosis by showing the pathological changes to the valve [1]. *Mitral regurgitation* - Characterized by a **holosystolic murmur** best heard at the **apex** and radiating to the axilla, associated with conditions like papillary muscle dysfunction or leaflet prolapse [2]. - While it can cause dyspnea, the murmur's location and timing, along with the specific echo findings of a calcified aortic valve, differentiate it from the patient's presentation [2]. *Tricuspid regurgitation* - Presents with a **holosystolic murmur** that increases with inspiration (Carvallo's sign) and is best heard at the **left lower sternal border**, often associated with and secondary to pulmonary hypertension. - This condition does not typically involve a calcified aortic valve or an ejection systolic murmur at the right upper sternal border. *Ventricular septal defect* - Typically causes a **harsh holosystolic murmur** best heard at the **left sternal border**, often associated with a thrill, and is usually diagnosed earlier in life. - While it can lead to dyspnea, the specific murmur features and echocardiographic findings presented in an elderly patient are inconsistent with an isolated VSD.

Q: What is the most appropriate initial treatment for a 58-year-old female with a history of breast cancer who presents with pulmonary embolism?

Low Molecular Weight Heparin (LMWH). ***Low Molecular Weight Heparin (LMWH)*** - **LMWH** is the preferred initial treatment for **pulmonary embolism** in patients with **cancer** due to its superior efficacy in preventing recurrence and ease of administration. - It has a lower risk of bleeding compared to unfractionated heparin and is more effective than vitamin K antagonists in cancer-associated thrombosis [2]. [3] *Inferior Vena Cava (IVC) filter without anticoagulation* - An **IVC filter** is reserved for patients with absolute **contraindications to anticoagulation** or recurrent VTE despite adequate anticoagulation [2]. - It does not treat the existing clot or prevent new clot formation in the pulmonary circulation; it only prevents further embolization from the lower extremities. *Systemic thrombolysis for immediate treatment* - **Systemic thrombolysis** is indicated only for patients with **massive pulmonary embolism** presenting with **hemodynamic instability** due to a high risk of major bleeding [1]. - The patient's presentation does not suggest hemodynamic instability, making thrombolysis highly risky and unnecessary as an initial treatment [1]. *Oral anticoagulants as initial therapy* - While **oral anticoagulants** (e.g., DOACs or warfarin) are used for long-term management of PE, they are generally not suitable for **initial treatment** of acute PE, especially in cancer patients, as they have a slower onset of action or require bridging with parenteral anticoagulants [2]. - **LMWH** provides rapid and reliable anticoagulation, which is crucial in the acute phase of PE to prevent further clot propagation and embolization [3].

Q: A 58-year-old man presents with chest pain and sweating. His ECG shows ST elevation in leads II, III, and aVF. What is the most likely location of the myocardial infarction?

Inferior wall. Detailed Analysis: ***Inferior wall*** - **ST elevation** in leads **II, III, and aVF** is the classic electrocardiographic finding for an **inferior wall myocardial infarction** [1]. - These leads correspond to the **diaphragmatic surface** of the heart, supplied primarily by the **right coronary artery** (RCA) in most individuals. *Anterior wall* - An **anterior wall myocardial infarction** typically shows **ST elevation** in leads **V1-V4** [2]. - This region is usually supplied by the **left anterior descending** (LAD) coronary artery. *Posterior wall* - A **posterior wall myocardial infarction** is often characterized by **ST depression** in leads **V1-V3** and prominent R waves, which are reciprocal changes to posterior ST elevation [2]. - This area is usually supplied by the **circumflex artery** or a dominant RCA. *Lateral wall* - A **lateral wall myocardial infarction** is indicated by **ST elevation** in leads **I, aVL, V5, and V6** [1]. - The lateral wall is primarily supplied by the **circumflex artery** or marginal branches of the LAD. *Symptoms* - Presenting symptoms such as chest pain and sweating (signs of sympathetic activation) are characteristic of acute myocardial ischemia [3].

Q: A 45-year-old male presents with palpitations and dizziness. His ECG shows a regular, narrow complex tachycardia at 180 bpm. Carotid massage and adenosine are ineffective. What is the likely diagnosis?

Focal atrial tachycardia. ***Focal atrial tachycardia*** - This is a **narrow complex tachycardia** that is typically **regular** and can be resistant to **adenosine** and **carotid massage**, making it a likely diagnosis when these vagal maneuvers are ineffective. - ECG often shows discrete **P waves** with an abnormal morphology and axis, followed by narrow QRS complexes, which distinguishes it from reentrant tachycardias that typically lack clear P waves. *Atrial fibrillation* - Characterized by an **irregularly irregular rhythm** and the **absence of distinct P waves** on ECG, which contradicts the described regular rhythm [1]. - While it can cause palpitations and dizziness, the lack of regularity rules it out in this scenario. *Atrial flutter* - Typically presents with a **sawtooth pattern** of P waves, known as flutter waves, which are not mentioned here. - Though it can be regular, it often responds to adenosine by slowing the ventricular rate, revealing the flutter waves, which did not occur after adenosine in this case. *Atrioventricular nodal reentrant tachycardia* - This is often a **regular, narrow complex tachycardia** [1] that is typically **terminated by vagal maneuvers** or **adenosine** which were ineffective in this patient. - The P waves are usually hidden within the QRS complex or appear immediately after it (pseudo-R' or pseudo-S waves), rather than clearly visible as in focal atrial tachycardia.

Q: A 40-year-old male presents with severe chest pain, hypotension, and distended neck veins. His ECG shows electrical alternans. What is the most likely diagnosis?

Pericardial tamponade. ***Pericardial tamponade*** - The combination of **chest pain**, **hypotension**, and **distended neck veins** (Beck's triad), along with **electrical alternans** on ECG, is highly indicative of pericardial tamponade. - **Electrical alternans** is caused by the heart "swinging" within the fluid-filled pericardial sac, leading to beat-to-beat variations in QRS amplitude. *Myocardial infarction* - While it can cause **chest pain** and **hypotension**, **distended neck veins** and **electrical alternans** are not typical findings. - ECG usually shows **ST-segment elevation** or depression, and/or **T-wave inversion**, depending on the type and location of the infarction. *Pulmonary embolism* - It can cause **chest pain** and **hypotension**, but **distended neck veins** are less common and typically associated with right heart strain, and **electrical alternans** is not a characteristic ECG finding. - ECG often shows **S1Q3T3 pattern** or **right bundle branch block**, acute right ventricular strain, and sinus tachycardia. *Aortic dissection* - It presents with severe, tearing **chest pain** that may radiate to the back and can cause **hypotension** due to hypovolemic shock (rupture into the pericardium/pleural space) or cardiac tamponade. - However, **electrical alternans** is not a direct consequence of aortic dissection, though it may occur if dissection leads to significant pericardial effusion and tamponade.

Q: Sinus bradycardia with myocardial infarction is best treated with:

Atropine. ***Atropine*** - **Atropine** is a **parasympatholytic agent** that blocks acetylcholine's action on muscarinic receptors, increasing heart rate. - It is the **first-line treatment** for hemodynamically significant **bradycardia** in the context of **myocardial infarction** to improve cardiac output [2]. *Dopamine* - While dopamine can increase heart rate and blood pressure, it is typically used for **hemodynamically unstable bradycardia** unresponsive to atropine. - Its **vasoconstrictive effects** can increase myocardial oxygen demand, which might be detrimental in **myocardial infarction**. *Isoproterenol* - **Isoproterenol** is a **non-selective beta-agonist** that increases heart rate and contractility. - Its use in **myocardial infarction** is generally avoided due to significant **tachycardic** and **arrhythmogenic effects**, which can worsen myocardial ischemia. *Temporary pacing* - **Temporary pacing** is reserved for **severe, symptomatic bradycardia** that is **refractory to pharmacological management** (e.g., atropine, dopamine) [2]. - It is an **invasive procedure** and not the initial treatment for sinus bradycardia with myocardial infarction unless other measures fail [1].

Q: A 70-year-old man with a long history of hypertension presents with sudden severe chest pain radiating to the back. CT angiography shows aortic dissection. What is the most common predisposing factor?

Hypertension. ***Hypertension*** - A **long history of hypertension** is the most significant predisposing factor for aortic dissection, as it increases the wall stress of the aorta [1]. - It can lead to **degeneration of the aortic media**, making it more susceptible to dissections [1]. *Bicuspid aortic valve* - While it can lead to **aortic stenosis** and other complications, it is not the **most common** predisposing factor for aortic dissection. - This condition primarily affects younger individuals, whereas dissection is more associated with **older age** and chronic hypertension. *Atherosclerosis* - Atherosclerosis contributes to **cardiovascular disease** but does not directly lead to aortic dissection as primarily as hypertension does. - It affects atherosclerotic plaque formation rather than the **structural integrity** of the aorta, which is pivotal in dissections [1]. *Marfan syndrome* - Although it is associated with aortic dissection [1], it is less common compared to **hypertension** in the general population. - Marfan syndrome is a genetic disorder, affecting connective tissue, which leads to dissection but is not as prevalent as chronic high blood pressure.

Question 1

A 62-year-old man with type 2 diabetes and a history of myocardial infarction is being treated for heart failure with reduced ejection fraction (HFrEF). According to the latest guidelines, which of the following medications should be added to optimize his treatment?

Accepted Answer

Sodium-glucose cotransporter-2 (SGLT2) inhibitor

Answer

Sacubitril/valsartan

Answer

Ivabradine

Answer

Digoxin

Question 2

Identify the primary drug used for pharmacological stress testing in echocardiography.

Accepted Answer

Dobutamine

Answer

Adenosine

Answer

Atropine

Answer

Diltiazem

Question 3

A 72-year-old female presents with dyspnea on exertion and an ejection systolic murmur best heard at the right upper sternal border. Echocardiography reveals a calcified aortic valve with restricted movement. What is the most likely diagnosis?

Accepted Answer

Aortic stenosis

Answer

Mitral regurgitation

Answer

Tricuspid regurgitation

Answer

Ventricular septal defect

Question 4

What is the most appropriate initial treatment for a 58-year-old female with a history of breast cancer who presents with pulmonary embolism?

Accepted Answer

Low Molecular Weight Heparin (LMWH)

Answer

Inferior Vena Cava (IVC) filter without anticoagulation

Answer

Systemic thrombolysis for immediate treatment

Answer

Oral anticoagulants as initial therapy

Question 5

A 58-year-old man presents with chest pain and sweating. His ECG shows ST elevation in leads II, III, and aVF. What is the most likely location of the myocardial infarction?

Accepted Answer

Inferior wall

Answer

Anterior wall

Answer

Posterior wall

Answer

Lateral wall

Question 6

A 45-year-old male presents with palpitations and dizziness. His ECG shows a regular, narrow complex tachycardia at 180 bpm. Carotid massage and adenosine are ineffective. What is the likely diagnosis?

Accepted Answer

Focal atrial tachycardia

Answer

Atrial fibrillation

Answer

Atrial flutter

Answer

Atrioventricular nodal reentrant tachycardia

Question 7

A 40-year-old male presents with severe chest pain, hypotension, and distended neck veins. His ECG shows electrical alternans. What is the most likely diagnosis?

Accepted Answer

Pericardial tamponade

Answer

Myocardial infarction

Answer

Pulmonary embolism

Answer

Aortic dissection

Question 8

What is the diagnostic utility of high-sensitivity troponin assays in the early detection of myocardial infarction?

Accepted Answer

High sensitivity and specificity for detecting myocardial infarction.

Answer

Low sensitivity; high specificity for detecting myocardial infarction.

Answer

High sensitivity; low specificity for detecting myocardial infarction.

Answer

Low sensitivity and specificity for detecting myocardial infarction.

Question 9

Sinus bradycardia with myocardial infarction is best treated with:

Accepted Answer

Atropine

Answer

Isoproterenol

Answer

Dopamine

Answer

Temporary pacing

Question 10

A 70-year-old man with a long history of hypertension presents with sudden severe chest pain radiating to the back. CT angiography shows aortic dissection. What is the most common predisposing factor?

Accepted Answer

Hypertension

Answer

Marfan syndrome

Answer

Bicuspid aortic valve

Answer

Atherosclerosis

Cardiology — MCQs

Cardiology — MCQs

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