Cardiology Practice Questions

Q: A systolic thrill in the left 2nd or 3rd intercostal space is heard in which of the following conditions?

Pulmonary stenosis. ***Pulmonary stenosis*** - A **systolic thrill** in the **left 2nd or 3rd intercostal space** is characteristic of significant **pulmonary stenosis**, where turbulent blood flow occurs across the narrowed pulmonary valve [1]. - The thrill is palpable over the **pulmonic area**, indicating high-velocity flow and pressure gradients [2]. *Tetralogy of Fallot (TOF)* - While TOF includes **pulmonary stenosis**, the primary thrill felt is typically due to the **right ventricular outflow tract obstruction** and is often accompanied by other findings like cyanosis [3]. - The thrill in TOF can be in the pulmonic area but is part of a more complex clinical picture, including a **ventricular septal defect** [3]. *Ebstein's anomaly (EA)* - **Ebstein's anomaly** involves the **tricuspid valve**, leading to tricuspid regurgitation and right atrial enlargement. - A thrill is not a typical finding; instead, auscultation might reveal a **holosystolic murmur of tricuspid regurgitation** at the lower left sternal border. *Subpulmonic ventricular septal defect (VSD)* - A **subpulmonic VSD** typically produces a **holosystolic murmur** best heard at the left sternal border, often accompanied by a thrill directly over the VSD [4]. - The thrill location for a VSD is generally more medial and lower than the pulmonic area [4].

Q: A 22-year-old woman is evaluated in the emergency department because of symptoms of prolonged palpitations. She complains of no associated chest discomfort, shortness of breath, or lightheadedness. The palpitations have occurred twice before, but they always stopped spontaneously after 5 minutes, and she cannot associate them with any triggers. The past health history is negative and she is not on any medications. On physical examination, the blood pressure is 110/70 mm Hg, heart rate is 160/min and regular. The heart and lung examinations are normal, and the ECG is shown in Figure below. The heart rate abruptly changes to 72/min after applying carotid sinus pressure. Which of the following is the most likely diagnosis?

Paroxysmal supraventricular tachycardia (PSVT). ***Paroxysmal supraventricular tachycardia (PSVT)*** - The abrupt onset and termination of palpitations, a regular rapid heart rate, and the response to **carotid sinus massage** are classic features of PSVT. - ECG typically shows a **narrow complex tachycardia** without clear P waves, which is consistent with the general description of the provided ECG. *Sinus tachycardia* - Sinus tachycardia typically has a **gradual onset and offset**, unlike the abrupt changes noted in the patient. - P waves would be visible and precede each QRS complex, which is not characteristic of the rapid, undifferentiated rhythm implied. *Paroxysmal atrial fibrillation* - Atrial fibrillation is characterized by an **irregularly irregular rhythm**, which contradicts the patient's regular heart rate of 160/min. - The ECG would show **absent P waves** and chaotic atrial activity, unlike the regular rhythm mentioned. *Paroxysmal atrial flutter* - Atrial flutter typically presents with a **sawtooth pattern of P waves** (flutter waves) on ECG, often with a fixed conduction ratio (e.g., 2:1, 3:1). - While it can be a regular tachycardia, the distinct flutter waves are a key diagnostic feature, and the described response to carotid massage leading to abrupt termination is less typical than with PSVT, which more often breaks the re-entrant circuit.

Q: All of the following may cause ST segment elevation on an EKG, except which of the following?

Constrictive pericarditis. ***Constrictive pericarditis*** - While **pericarditis** can cause ST elevation due to inflammation of the epicardial layer [1], **constrictive pericarditis** primarily leads to **reduced diastolic filling** and rarely causes ST elevation. - ECG findings in constrictive pericarditis typically include **low voltage QRS complexes** and **T-wave flattening or inversion**, not ST elevation. *Early repolarization variant* - This is a **benign ECG finding** often seen in young, healthy individuals, characterized by **notching or slurring** at the end of the QRS complex (J-point elevation) with upwardly concave ST segments [1]. - It's a **normal variant** and not indicative of myocardial injury, despite the ST elevation. *Ventricular aneurysm* - A **ventricular aneurysm**, a non-contractile area of myocardial scar tissue, typically results in **persistent ST elevation** after an acute myocardial infarction in the leads corresponding to the aneurysm. - The ST elevation is usually **fixed** and observed in the setting of prior MI. *Prizmetal angina* - Also known as **vasospastic angina**, this condition involves **coronary artery spasm** causing transient myocardial ischemia, which manifests as **ST segment elevation** during episodes of chest pain. - The ST elevation resolves once the spasm ceases, differentiating it from an STEMI.

Q: Which of the following is true about the bicuspid aortic valve?

Diagnosis is made by echocardiography. ### Diagnosis is made by echocardiography - **Echocardiography** is the gold standard for diagnosing a bicuspid aortic valve, as it allows direct visualization of the valve's morphology and assessment of its function (stenosis or regurgitation). - This imaging modality can identify the **two cusps** instead of the usual three, quantify blood flow, and assess for associated abnormalities. *It is more common in females than in males* - The bicuspid aortic valve is actually **more common in males** than in females, with a male-to-female ratio of about 2:1 to 4:1. - It is one of the **most common congenital heart defects**, affecting approximately 1-2% of the general population. *Usually undetected in early life* - While some cases might be asymptomatic early on, many individuals with a bicuspid aortic valve are diagnosed in **childhood or adolescence** due to associated murmurs or symptoms like chest pain or shortness of breath during exertion. - Its presence often predisposes individuals to complications like **aortic stenosis** [1] or regurgitation [2], which can manifest at any age [2]. *Post-stenotic dilatation of ascending aorta can be seen* - While **post-stenotic dilatation** of the ascending aorta can indeed be seen in patients with a bicuspid aortic valve, this statement on its own is not the most definitive truth about the diagnosis because it describes a complication or associated finding, not the primary method of diagnosis. - Aortic dilatation is a common finding due to **abnormal wall stress** and intrinsic medial weakness, often observed in conjunction with the bicuspid valve.

Q: In a patient with subclavian steal syndrome, what is the most characteristic finding?

The BP is decreased on the ipsilateral side. ***The BP is decreased on the ipsilateral side*** - Subclavian steal syndrome is caused by a **stenosis** or **occlusion** of the **subclavian artery** proximal to the origin of the vertebral artery. This leads to reduced blood flow to the ipsilateral arm, resulting in a **decreased blood pressure** in that arm. [1] - The pressure difference between the unaffected and affected arm is typically **greater than 15-20 mmHg**, which is a key diagnostic clue. *The flow of blood in the vertebral arteries is normal* - In subclavian steal syndrome, the blood flow in the **ipsilateral vertebral artery** can be **reversed** or significantly reduced. - This reversal of flow occurs as the vertebral artery "steals" blood from the vertebrobasilar circulation to supply the ischemic arm. *The patients may present with claudication features in some cases.* - While patients can experience **arm claudication** (pain, fatigue, or numbness during exercise) due to reduced blood flow to the arm, this is a symptom rather than the **most characteristic finding** related to the underlying hemodynamics. - Arm claudication occurs when the **demand for blood flow** to the ipsilateral arm muscles exceeds the compromised supply, often during arm exercise. *The patients may present with neurological features.* - Neurological symptoms, such as **dizziness, vertigo, diplopia, or syncope**, can occur due to **vertebrobasilar insufficiency** when blood is "stolen" from the cerebral circulation. - However, the **most characteristic hemodynamic finding** directly reflecting the subclavian artery stenosis is the **blood pressure differential** in the arms.

Q: Extent of cardiotoxicity of chemotherapy and radiotherapy is best diagnosed by:

Echocardiogram. Echocardiogram - An echocardiogram is the most common and widely used non-invasive diagnostic tool to assess cardiac function and structure, including left ventricular ejection fraction (LVEF), which is crucial for monitoring cardiotoxicity [1]. - It can detect changes in ventricular size, wall motion abnormalities, and valvular function that may arise from chemotherapy or radiotherapy-induced damage [1]. Radionuclide scan - Radionuclide scans, such as MUGA (Multigated Acquisition) scans, can also assess LVEF but involve radiation exposure and are generally reserved for cases where echocardiography is suboptimal or yields equivocal results. - While sensitive, it's not the primary or initial diagnostic test due to its invasive nature and cost compared to echocardiography. ECG - An ECG (electrocardiogram) assesses the electrical activity of the heart but provides limited information about structural or functional changes indicative of cardiotoxicity [2]. - It can detect arrhythmias or ischemic changes but is not specific enough to determine the extent of myocardial damage from chemotherapy or radiotherapy [2]. Endomyocardial biopsy - Endomyocardial biopsy is an invasive procedure that provides a definitive histological diagnosis of myocardial damage but is rarely performed due to its invasiveness, risk of complications, and the availability of less invasive methods. - It is typically reserved for unexplained severe cardiac dysfunction or for specific research protocols, not routine monitoring of cardiotoxicity.

Q: Which of the following is true about torsades de pointes?

Presence of prolonged QT interval on ECG. ***Presence of prolonged QT interval on ECG*** - Torsades de pointes is a polymorphic ventricular tachycardia associated with a **prolonged QT interval**, which often precedes the arrhythmia [1]. - A prolonged QT interval indicates a delayed repolarization of the ventricles, creating a vulnerable period for the development of aberrant electrical activity [2]. *Presence of polymorphic QRS complexes* - While torsades de pointes does exhibit **polymorphic QRS complexes**, this is a characteristic *feature* of the arrhythmia itself, not the primary predisposing factor or defining characteristic that initiates it [1]. - The key underlying condition leading to torsades is the **QT prolongation**. *It is a type of supraventricular tachycardia* - Torsades de pointes is a **ventricular tachycardia**, meaning it originates in the ventricles, not above them in the atria or AV node (supraventricular) [1]. - Its origin below the Bundle of His differentiates it from supraventricular arrhythmias. *QRS complexes appear to rotate around the isoelectric baseline of ECG* - This description accurately depicts the characteristic **"twisting of the points"** morphology of torsades de pointes, but it is a *description of the ECG appearance* during the arrhythmia itself, not the fundamental predisposing factor [1]. - The rotation is a consequence of the changing amplitudes and axes of the polymorphic QRS complexes [1].

Q: Ankle-brachial index is useful in prediction of:

Myocardial infarction. ***Myocardial infarction*** - A low **ankle-brachial index (ABI)** indicates broader **atherosclerotic disease**, which is a significant **risk factor** for **myocardial infarction** and other **cardiovascular events** [1]. - ABI measures arterial insufficiency in the lower extremities; a value less than 0.9 suggests **peripheral artery disease (PAD)**, independently predicting future cardiac events [1]. *Buerger's disease* - Not directly predicted by ABI in the context of general cardiovascular risk; **Buerger's disease** is an **inflammatory vasculitis** primarily affecting small and medium-sized arteries and veins. - While it causes digital ischemia, its etiology and pathophysiology are distinct from the general atherosclerotic burden measured by ABI. *Meconium ileus* - **Meconium ileus** is a **gastrointestinal obstruction** in newborns, typically associated with **cystic fibrosis**, and has no relationship with the **ankle-brachial index** measurement. - ABI is a vascular diagnostic tool, not relevant to pediatric gastrointestinal conditions. *All of the options* - This is incorrect because **meconium ileus** and **Buerger's disease** are not primarily or directly predicted by the ankle-brachial index. - ABI is a strong predictor of systemic atherosclerosis and associated events like myocardial infarction, but not unrelated conditions [1].

Q: Reversed Coarctation is seen in which of the following conditions?

Takayasu Arteritis. **Takayasu Arteritis** - **Reversed coarctation** (or paradoxical coarctation) is a characteristic feature of **Takayasu arteritis**, where narrowing or occlusion mainly affects the **aortic arch** and its branches, leading to a reversed pressure gradient in the upper extremities compared to the lower extremities. - This condition is a **large-vessel vasculitis** primarily affecting the aorta and its major branches, causing ischemia to the upper body and head. *Polyarteritis Nodosa* - This is a **medium-sized vessel vasculitis** that typically affects renal and visceral arteries, leading to aneurysms and occlusions. - It does not primarily affect the aortic arch or present with reversed coarctation. *Kawasaki Disease* - **Kawasaki disease** is a **medium-sized vessel vasculitis** predominantly affecting children, which can cause coronary artery aneurysms. - It does not involve the large vessels of the aortic arch to cause reversed coarctation. *Giant cell Arteritis* - **Giant cell arteritis (GCA)** is a **large-vessel vasculitis** primarily affecting the aorta and its major branches, but typically involves the **temporal arteries**. - While it can affect the aorta, it is more commonly associated with headaches and jaw claudication, and reversed coarctation is not a prominent feature.

Question 1

A systolic thrill in the left 2nd or 3rd intercostal space is heard in which of the following conditions?

Accepted Answer

Pulmonary stenosis

Answer

Tetralogy of Fallot (TOF)

Answer

Ebstein's anomaly (EA)

Answer

Subpulmonic ventricular septal defect (VSD)

Question 2

A 22-year-old woman is evaluated in the emergency department because of symptoms of prolonged palpitations. She complains of no associated chest discomfort, shortness of breath, or lightheadedness. The palpitations have occurred twice before, but they always stopped spontaneously after 5 minutes, and she cannot associate them with any triggers. The past health history is negative and she is not on any medications. On physical examination, the blood pressure is 110/70 mm Hg, heart rate is 160/min and regular. The heart and lung examinations are normal, and the ECG is shown in Figure below. The heart rate abruptly changes to 72/min after applying carotid sinus pressure. Which of the following is the most likely diagnosis?

Accepted Answer

Paroxysmal supraventricular tachycardia (PSVT)

Answer

Sinus tachycardia

Answer

Paroxysmal atrial fibrillation

Answer

Paroxysmal atrial flutter

Question 3

All of the following may cause ST segment elevation on an EKG, except which of the following?

Accepted Answer

Constrictive pericarditis

Answer

Ventricular aneurysm

Answer

Prizmetal angina

Answer

Early repolarization variant

Question 4

Which of the following is true about the bicuspid aortic valve?

Accepted Answer

Diagnosis is made by echocardiography

Answer

It is more common in females than in males

Answer

Post-stenotic dilatation of ascending aorta can be seen

Answer

Usually undetected in early life

Question 5

In a patient with subclavian steal syndrome, what is the most characteristic finding?

Accepted Answer

The BP is decreased on the ipsilateral side

Answer

The flow of blood in the vertebral arteries is normal

Answer

The patients may present with claudication features in some cases.

Answer

The patients may present with neurological features.

Question 6

Extent of cardiotoxicity of chemotherapy and radiotherapy is best diagnosed by:

Accepted Answer

Echocardiogram

Answer

Radionuclide scan

Answer

ECG

Answer

Endomyocardial biopsy

Question 7

Which of the following rhythms associated with cardiac arrest is considered shockable?

Accepted Answer

Ventricular fibrillation

Answer

Pulseless ventricular tachycardia

Answer

Asystole

Answer

Pulseless electrical activity

Question 8

Which of the following is true about torsades de pointes?

Accepted Answer

Presence of prolonged QT interval on ECG

Answer

Presence of polymorphic QRS complexes

Answer

It is a type of supraventricular tachycardia

Answer

QRS complexes appear to rotate around the isoelectric baseline of ECG

Question 9

Ankle-brachial index is useful in prediction of:

Accepted Answer

Myocardial infarction

Answer

All of the options

Answer

Buerger's disease

Answer

Meconium ileus

Question 10

Reversed Coarctation is seen in which of the following conditions?

Accepted Answer

Takayasu Arteritis

Answer

Polyarteritis Nodosa

Answer

Kawasaki Disease

Answer

Giant cell Arteritis

Cardiology — MCQs

Cardiology — MCQs

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