Cardiology Practice Questions

Q: A 36-year-old patient presents to the emergency department with shock. His ECG shows ST elevation in leads II and III and aVF. What is the most likely cause of shock?

Right ventricular infarction. ***Right ventricular infarction*** - **ST elevation in leads II, III, and aVF** indicates an **inferior myocardial infarction**, which commonly extends to involve the right ventricle. - Involvement of the right ventricle significantly impairs its ability to pump blood, leading to a **preload-dependent state** and **cardiogenic shock**. *Papillary muscle rupture* - While it can cause shock due to **acute mitral regurgitation**, it typically occurs later (2-7 days) post-infarction and might not present immediately with shock in acute MI diagnosis. - The primary ECG finding would still be indicative of the original infarction, but the shock would clinically manifest as signs of severe **mitral regurgitation** (e.g., new murmur, flash pulmonary edema). *Cardiac rupture* - This catastrophic event usually leads to **cardiac tamponade** and immediate demise, often without presenting to the ED in a stable enough condition for diagnosis. - It also tends to occur later (within the first week) after an MI, rather than being the immediate cause of shock upon presentation. *Septal perforation* - Results in a **ventricular septal defect**, causing a left-to-right shunt and can lead to shock due to **volume overload** and **pulmonary edema**. - It typically manifests as a **holosystolic murmur** and occurs later post-MI (days to weeks), not usually as the initial presentation of shock in acute MI.

Q: A 68-year-old man presents with a syndrome of alcohol withdrawal. His ECG shows a regular narrow complex tachycardia at 150 bpm with characteristic sawtooth waves. What is the most likely diagnosis?

Atrial flutter. ***Atrial flutter*** - The ECG finding of a **regular narrow complex tachycardia at 150 bpm** with characteristic **sawtooth waves** is pathognomonic for **atrial flutter** [1]. - Alcohol withdrawal can trigger atrial arrhythmias due to increased **sympathetic tone** and electrolyte disturbances. *Atrial fibrillation* - Characterized by an **irregularly irregular rhythm** with no distinct P waves, which contrasts with the regular rhythm and sawtooth waves seen [1]. - While common in alcohol withdrawal, the ECG description does not fit atrial fibrillation. *PSVT* - **Paroxysmal supraventricular tachycardia (PSVT)** is typically a regular narrow complex tachycardia, but it **lacks the sawtooth flutter waves** seen in the ECG [2]. - ECG usually shows sudden onset and termination, often with obscured P waves, but not the distinct flutter waves [3]. *VT* - **Ventricular tachycardia (VT)** is generally characterized by a **wide QRS complex** (>0.12 seconds), which is not consistent with a "narrow complex tachycardia" [4]. - While VT can be regular, it originates from the ventricles and would not show atrial sawtooth waves [4].

Q: What type of murmur is most likely associated with a patient presenting with elevated JVP, large v-waves, and a loud systolic murmur?

Tricuspid regurgitation. ***Tricuspid regurgitation*** - **Elevated JVP** with prominent **v-waves** and a **loud systolic murmur** are classic findings for tricuspid regurgitation. [1] The large v-waves are due to blood regurgitating into the right atrium during ventricular systole. - The murmur is typically **holosystolic** and may increase with inspiration (Carvallo's sign). *Functional murmur* - Functional murmurs are generally **benign**, not associated with significant hemodynamic compromise, and rarely present with elevated JVP or prominent v-waves. - They are typically **soft**, early or mid-systolic, and often change intensity with position. *Tricuspid stenosis* - Tricuspid stenosis would cause an **elevated JVP**, but the prominent wave would be an **a-wave** (due to increased right atrial pressure during atrial contraction), not a v-wave. - The murmur associated with tricuspid stenosis is a **diastolic rumble**, not a systolic murmur. [3] *Pulmonary stenosis* - Pulmonary stenosis presents with a **systolic ejection murmur** at the upper left sternal border and can cause elevated JVP due to right ventricular hypertrophy and failure. [2] - However, it typically does not cause prominent **v-waves** in the JVP, as the issue is outflow obstruction from the right ventricle, not regurgitation into the right atrium.

Q: Manifestations of acute aortic dissection include all of the following, except:

Mitral Regurgitation (MR). ***Mitral Regurgitation (MR)*** - **Mitral regurgitation** is not a typical direct manifestation of acute aortic dissection. The mitral valve is anatomically separate from the aorta [3]. - While indirect effects on the heart can occur, direct **MR** is highly unlikely as a primary presentation of acute aortic dissection. *Pericardial effusion* - An acute aortic dissection, especially of the ascending aorta, can rupture into the **pericardial space**, leading to **pericardial effusion** and potentially **cardiac tamponade** [2]. - This occurs due to blood leaking from the dissected aorta into the confines of the pericardium. *AR* - **Aortic regurgitation (AR)** is a common and serious complication of acute aortic dissection when the dissection involves the **aortic root** and disrupts the integrity of the aortic valve leaflets or their support structures [1]. - This can lead to new onset or worsening AR, causing acute heart failure. *AMI* - **Acute myocardial infarction (AMI)** can result from an acute aortic dissection if the dissection flap extends into or compromises the ostium of a **coronary artery**, particularly the right coronary artery [1]. - This occlusion of a coronary artery by the dissecting hematoma or flap leads to **myocardial ischemia** and infarction.

Q: Hockey stick appearance on echo is a feature of.

Mitral stenosis. ***Mitral stenosis*** - The **"hockey stick" appearance** on echocardiography refers to the characteristic **doming of the anterior mitral leaflet** during diastole, which is a hallmark of mitral stenosis. - This doming is due to the stenotic mitral valve opening incompletely, with the tip of the leaflet bending forward while its base remains tethered [1]. *Mitral incompetence* - **Mitral incompetence (regurgitation)** is characterized by **incomplete closure** of the mitral valve leaflets, leading to backward blood flow into the left atrium during systole. - This condition does not typically present with a "hockey stick" appearance; instead, it is often seen with **leaflet prolapse** or inadequate coaptation [1]. *Aortic stenosis* - **Aortic stenosis** involves the **narrowing of the aortic valve**, impeding blood flow from the left ventricle to the aorta. - Its echocardiographic features include **thickened, calcified aortic valve leaflets** with reduced excursion, not a "hockey stick" appearance. *Aortic regurgitation* - **Aortic regurgitation** is the backward flow of blood from the aorta into the left ventricle during diastole due to **incomplete closure of the aortic valve** [2]. - While it can manifest with various echocardiographic signs like **diastolic flow reversal** in the aorta, the "hockey stick" sign is not associated with this condition [2].

Q: What is an electrical storm?

3 episodes of ventricular tachycardia within 24 hours. ***3 episodes of ventricular tachycardia within 24 hours*** - An **electrical storm**, also known as **arrhythmia storm**, is defined by the occurrence of **three or more distinct episodes of ventricular tachycardia (VT)**, ventricular fibrillation (VF), or appropriate implantable cardioverter-defibrillator (ICD) shocks within a 24-hour period [1]. - This condition signifies **severe myocardial electrical instability** and is associated with increased morbidity and mortality [1]. *Electromechanical dissociation* - **Electromechanical dissociation (EMD)**, or pulseless electrical activity (PEA), describes a situation where there is organized electrical activity on an electrocardiogram but **no palpable pulse**. - It is a form of cardiac arrest and is distinct from an arrhythmia storm, which specifically refers to recurrent ventricular arrhythmias. *Electrical alternans* - **Electrical alternans** is an electrocardiographic phenomenon characterized by **beat-to-beat alterations in the QRS complex amplitude or axis**. - It is often associated with **pericardial effusion with cardiac tamponade** and is not indicative of recurrent ventricular tachyarrhythmias. *3 episodes of atrial tachycardia within 24 hours* - While recurrent **atrial tachycardia** indicates electrical instability in the atria, an "electrical storm" specifically refers to **ventricular arrhythmias** [1]. - Atrial arrhythmias, though potentially serious, do not meet the diagnostic criteria for an electrical storm.

Q: The given ECG shows the following findings:

Acute pulmonary embolism. ***Acute pulmonary embolism*** - This ECG shows the classic **S1Q3T3 pattern**, characterized by a **prominent S wave in lead I**, a **Q wave in lead III**, and an **inverted T wave in lead III**, which is highly suggestive of acute pulmonary embolism. - Other common ECG findings in pulmonary embolism include **sinus tachycardia**, **right axis deviation**, and right bundle branch block, all pointing to acute right heart strain. *Hypertrophic cardiomyopathy (HCM)* - HCM typically presents with **deep, narrow Q waves** in the inferolateral leads (II, III, aVF, V5, V6) due to septal hypertrophy. - It usually does not exhibit the S1Q3T3 pattern. *Pericardial effusion (PE)* - Pericardial effusion usually causes **low voltage QRS complexes** and **electrical alternans** due to the fluid surrounding the heart. - It does not present with the specific S1Q3T3 pattern seen here. *Anterior wall myocardial infarction (MI)* - Anterior MI is characterized by **ST-segment elevation** (or Q waves in later stages) in the anterior leads (V1-V4). - While it can cause T wave inversions, it would not typically show the S1Q3T3 pattern.

Q: Positive hepatojugular reflux is found in all of the following conditions except -

Decreased afterload. ***Decreased afterload*** - **Hepatojugular reflux** is a sign of **right-sided heart dysfunction** [1] where compressing the liver increases jugular venous pressure due to impaired right ventricular filling [2]. - **Decreased afterload** would typically improve cardiac output and reduce intracardiac pressures, making hepatojugular reflux less likely. *Tricuspid regurgitation* - **Tricuspid regurgitation** leads to increased right atrial pressure [2], which can cause engorgement of the liver and an exaggerated hepatojugular reflux. - This condition directly impacts the ability of the right ventricle to empty effectively, contributing to systemic venous congestion. *Right heart failure* - **Right heart failure** is a common cause of hepatojugular reflux due to elevated right atrial and central venous pressures [1]. - The failing right ventricle is unable to handle increased venous return, leading to reflux. *Increased capillary bed pressure* - **Increased capillary bed pressure** in the systemic circulation, often secondary to **right heart failure** [2] or **volume overload**, contributes to elevated venous pressures. - This increased pressure can be transmitted back to the right atrium, leading to a positive hepatojugular reflux.

Q: What is the immediate treatment modality for a patient presenting with acute anterior wall myocardial infarction and hypotension?

Primary Percutaneous Coronary Intervention (Primary PCI). ***Primary Percutaneous Coronary Intervention (Primary PCI)*** - **Primary PCI**, guided by coronary angiography, is the **gold standard** for treating ST-elevation myocardial infarction (STEMI) because it directly restores blood flow to the *ischemic* myocardium. - In a patient with **acute anterior wall MI and hypotension**, immediate revascularization via Primary PCI is crucial to improve cardiac output and stabilize hemodynamics, as hypotension often implies significant myocardial damage and *cardiogenic shock*. - Guidelines recommend Primary PCI within **90 minutes** of first medical contact (door-to-balloon time) when available. *Thrombolytic therapy* - While thrombolysis can restore blood flow, it is considered a **second-line treatment** if PCI is unavailable or significantly delayed (>120 minutes from first medical contact). - It carries a higher risk of bleeding complications and may not achieve complete reperfusion, especially in patients with **hypotension** or *cardiogenic shock*. *Anticoagulation* - Anticoagulation is an **adjunctive therapy** used to prevent further clot formation and maintain coronary artery patency after reperfusion. - It is **not a definitive revascularization strategy** on its own and does not immediately address the acute coronary occlusion causing the MI and hypotension. *Intra-aortic balloon counterpulsation (IABP)* - **IABP** is a mechanical circulatory support device used to reduce *afterload* and increase *coronary perfusion*, primarily in patients with **cardiogenic shock** awaiting or recovering from revascularization. - While beneficial for hemodynamic support, it is **not the primary reperfusion treatment** and should be used in conjunction with immediate PCI, not as a substitute.

Question 1

A 36-year-old patient presents to the emergency department with shock. His ECG shows ST elevation in leads II and III and aVF. What is the most likely cause of shock?

Accepted Answer

Right ventricular infarction

Answer

Papillary muscle rupture

Answer

Cardiac rupture

Answer

Septal perforation

Question 2

A 68-year-old man presents with a syndrome of alcohol withdrawal. His ECG shows a regular narrow complex tachycardia at 150 bpm with characteristic sawtooth waves. What is the most likely diagnosis?

Accepted Answer

Atrial flutter

Answer

Atrial fibrillation

Answer

PSVT

Answer

VT

Question 3

What type of murmur is most likely associated with a patient presenting with elevated JVP, large v-waves, and a loud systolic murmur?

Accepted Answer

Tricuspid regurgitation

Answer

Functional murmur

Answer

Tricuspid stenosis

Answer

Pulmonary stenosis

Question 4

Manifestations of acute aortic dissection include all of the following, except:

Accepted Answer

Mitral Regurgitation (MR)

Answer

Pericardial effusion

Answer

AR

Answer

AMI

Question 5

Hockey stick appearance on echo is a feature of.

Accepted Answer

Mitral stenosis

Answer

Mitral incompetence

Answer

Aortic stenosis

Answer

Aortic regurgitation

Question 6

What is an electrical storm?

Accepted Answer

3 episodes of ventricular tachycardia within 24 hours

Answer

Electromechanical dissociation

Answer

Electrical alternans

Answer

3 episodes of atrial tachycardia within 24 hours

Question 7

The given ECG shows the following findings:

Accepted Answer

Acute pulmonary embolism

Answer

Hypertrophic cardiomyopathy (HCM)

Answer

Pericardial effusion (PE)

Answer

Anterior wall myocardial infarction (MI)

Question 8

Which of the following statements regarding hypertensive crisis is false?

Accepted Answer

Hypertensive emergencies require immediate reduction of blood pressure over hours to prevent end-organ damage.

Answer

Hypertensive urgencies may be managed without extensive monitoring on an outpatient basis.

Answer

Hypertensive urgency is characterized by marked elevation of blood pressure without rapidly evolving end organ damage.

Answer

None of the options.

Question 9

Positive hepatojugular reflux is found in all of the following conditions except -

Accepted Answer

Decreased afterload

Answer

Tricuspid regurgitation

Answer

Increased capillary bed pressure

Answer

Right heart failure

Question 10

What is the immediate treatment modality for a patient presenting with acute anterior wall myocardial infarction and hypotension?

Accepted Answer

Primary Percutaneous Coronary Intervention (Primary PCI)

Answer

Anticoagulation

Answer

Thrombolytic therapy

Answer

Intra-aortic balloon counterpulsation

Cardiology — MCQs

Cardiology — MCQs

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