Cardiology Practice Questions

Q: In the ECG shown below, which drug should be avoided in the management of atrial fibrillation?

Adenosine. ***Adenosine*** - The ECG shows **atrial fibrillation with rapid ventricular response** and **delta waves**, indicating **Wolff-Parkinson-White (WPW) syndrome**. - **Adenosine** blocks the AV node, which can increase conduction down the accessory pathway in WPW, potentially leading to **ventricular fibrillation**. *Amiodarone* - While it can be used for rate and rhythm control in atrial fibrillation, it is not absolutely contraindicated in the setting of WPW and may be considered with caution after other options. - However, in acute settings with WPW and rapid Afib, it is not the first-line and might not be as rapidly effective in preventing ventricular arrhythmias as procainamide or cardioversion. *Diltiazem* - **Diltiazem** is a calcium channel blocker that slows conduction through the AV node. - Like adenosine, blocking the AV node in the presence of an accessory pathway can dangerously increase conduction over the accessory pathway, leading to a faster ventricular response and potential **ventricular fibrillation**. *Beta-blocker* - **Beta-blockers** also slow conduction through the AV node, similar to calcium channel blockers and adenosine. - In patients with **WPW syndrome** and atrial fibrillation, blocking the AV node can divert impulses down the accessory pathway, potentially leading to a more rapid ventricular rate and **ventricular fibrillation**.

Q: Which of the following statements regarding the left parasternal lift are NOT true?

All of the options. *All of the options* - This question asks for statements that are **NOT true**, and all listed options contain inaccuracies regarding the timing and physiological correlates of a left parasternal lift. [2] - A left parasternal lift, or heave, is typically associated with **right ventricular hypertrophy** or dilation, reflecting right ventricular activity rather than direct left ventricular events. [2], [3] *Synchronous with left ventricular apical impulse.* - A left parasternal lift is a palpable impulse over the **right ventricle**, while the apical impulse primarily represents the **left ventricular apex**. [2] These are distinct and not synchronous in the manner implied. [1] - While both occur during systole, they represent different ventricular actions and locations, making their direct synchronicity in terms of representing the same event incorrect. [1] *Starts in early systole.* - A left parasternal lift reflecting **right ventricular systole** begins with isovolumetric contraction of the right ventricle, which is indeed in early systole. [1] - However, the overall premise of the question is to identify incorrect statements about a left parasternal lift; while this particular point about timing is generally correct for right ventricular contraction, its inclusion here is part of identifying the broader inaccuracies in the other options if they are considered in the context of what a left parasternal lift *is not*. *Corresponds to 'V' wave in LA pressure curve.* - The 'V' wave in the left atrial (LA) pressure curve represents **passive filling** of the left atrium during ventricular systole and subsequent atrial volume overload, not a direct mechanical event like a parasternal lift. - A left parasternal lift is a **palpable chest wall movement** due to right ventricular activity, unrelated to the 'V' wave of left atrial pressure. [2]

Q: Which of the following statements is true about infective endocarditis in IV drug abusers?

Tricuspid valve is most commonly involved. ***Tricuspid valve is most commonly involved*** - In **IV drug abusers**, the **tricuspid valve** is most often affected due to direct inoculation of pathogens through contaminated needles. - This results in **right-sided endocarditis**, commonly associated with **Staphylococcus aureus** infections [2], [3]. *Staphylococcus aureus is the most common organism.* - While **Staphylococcus aureus** is prevalent [3], [4], it is **not the only organism**; other bacteria can also cause infective endocarditis in this population. - The statement is somewhat misleading as it does not emphasize the broader range of organisms involved. *Pulmonary valve is commonly involved* - The **pulmonary valve** is typically not affected in infective endocarditis related to IV drug use; the focus is primarily on the **tricuspid valve**. - Right-sided endocarditis predominantly affects the **tricuspid valve** due to the route of infection, making this statement incorrect. *Candida is a common cause of infective endocarditis.* - **Candida** is a rare cause of infective endocarditis compared to bacterial causes, especially in IV drug users [1]. - This fungal organism is more associated with **compromised immunity** and not common in standard settings of IV drug abuse, though it can occur via contamination of lemon juice [1].

Q: Intracavitary electrocardiography is a diagnostic aid in which of the following conditions?

Ebstein's anomaly of the tricuspid valve. ***Ebstein's anomaly of the tricuspid valve*** - Intracavitary electrocardiography (ECG) is particularly useful in distinguishing **Ebstein's anomaly** from other conditions due to its ability to localize the AV conduction tissue relative to the tricuspid valve. - In Ebstein's anomaly, the **atrialized right ventricle** can be identified by the presence of a ventricular electrogram atrialized segment, which helps characterize the extent of tricuspid valve displacement. *Tricuspid valve stenosis* - While tricuspid valve stenosis affects the right heart, its primary diagnosis is made through **echocardiography** to assess flow obstruction and valve morphology. - Intracavitary ECG is not a standard or primary diagnostic tool for characterizing the anatomical features or hemodynamic severity of **tricuspid stenosis**. *Atrial septal defect* - An **atrial septal defect (ASD)** is typically diagnosed by **echocardiography**, which directly visualizes the defect and assesses shunt size and direction. - Intracavitary ECG is not routinely used for localizing or diagnosing an ASD, as its role is more focused on cardiac conduction and chamber electrophysiology. *Ventricular septal defect* - A **ventricular septal defect (VSD)** is primarily diagnosed using **echocardiography**, which offers clear visualization of the defect location, size, and hemodynamic impact. - Although VSDs can affect ventricular electrophysiology, intracavitary ECG is not a primary diagnostic tool for identifying or characterizing a VSD itself.

Q: A 50-year-old man with a history of smoking, hypertension, and chronic exertional angina develops several daily episodes of chest pain at rest compatible with cardiac ischemia. The patient is hospitalized. All the following would be part of an appropriate management plan except one.

Lidocaine. ***Lidocaine*** - **Lidocaine** is an antiarrhythmic drug primarily used for the treatment of **ventricular arrhythmias**, particularly in the setting of acute myocardial infarction [3]. - It is not a standard component of initial management for **unstable angina** or **non-ST elevation myocardial infarction (NSTEMI)** in the absence of documented ventricular arrhythmias. *Intravenous heparin* - **Intravenous heparin** is critical in the management of unstable angina and NSTEMI to prevent further thrombus formation. - It works by potentiation of **antithrombin III**, which inhibits the activity of thrombin and factor Xa. *Aspirin* - **Aspirin** is an essential antiplatelet agent used immediately in patients with acute coronary syndromes [2]. - It inhibits **cyclooxygenase-1 (COX-1)**, reducing thromboxane A2 production and thus **platelet aggregation** [3]. *Beta-blockers* - **Beta-blockers** are indicated to reduce myocardial oxygen demand by decreasing heart rate, blood pressure, and myocardial contractility [1]. - They help to alleviate angina symptoms and improve outcomes in patients with acute coronary syndromes by balancing **myocardial oxygen supply and demand** [1].

Q: A young basketball player with a height of 188 cm and an arm span of 197 cm has a diastolic murmur best heard in the second right intercostal space. The likely cause of the murmur is:

AR. **AR** - **Aortic regurgitation** (AR) often presents as a **diastolic murmur** [1] best heard at the **second right intercostal space**, especially in the context of an athletic individual with features suggestive of connective tissue disorder (increased arm span relative to height, potentially indicating **Marfanoid habitus**). - AR symptoms, such as the diastolic murmur, arise from blood flowing back into the **left ventricle** during diastole [1] due to an incompetent aortic valve [2]. *AS* - **Aortic stenosis** (AS) typically presents as a **systolic ejection murmur** best heard at the **second right intercostal space**, radiating to the carotids, significantly different from the described diastolic murmur. - While congenital bicuspid aortic valve can lead to AS and is common in athletes, the timing of the murmur (systolic vs. diastolic) rules out primary AS as the cause here. *Coarctation of the aorta* - **Coarctation of the aorta** does not typically cause a diastolic murmur in the second right intercostal space; it is more associated with blood pressure discrepancies between upper and lower extremities and a **systolic murmur** heard over the back or left infraclavicular area. - Although it can be seen in athletes, its clinical presentation (murmur location and timing, blood pressure findings) does not match the patient's presentation. *MR* - **Mitral regurgitation** (MR) results in a **holosystolic murmur** best heard at the **apex** and often radiating to the axilla, which is neither diastolic nor heard in the second right intercostal space. - The location and timing of the murmur described in the question are inconsistent with MR.

Q: All of the following are features of a benign heart murmur except which of the following?

Radiating to the lower chest. ***Radiating to the lower chest*** - Benign murmurs are typically **localized** and **do not radiate widely**, especially not to the lower chest. [1] - Radiation suggests a more significant flow disturbance and is often a feature of **pathological murmurs**, indicating conditions like **aortic stenosis** (radiating to the carotids) or **mitral regurgitation** (radiating to the axilla). [1] *Mid systolic* - Many benign murmurs are **mid-systolic**, often referred to as **ejection murmurs**, which are common due to normal blood flow turbulence. [1] - This timing is characteristic of functional murmurs arising from the **right ventricular outflow tract** or **aortic root**. *Heard at the left sternal area* - Benign murmurs are frequently heard at the **left sternal border**, particularly in the **pulmonic area (2nd and 3rd intercostal spaces)**, often due to flow across the pulmonic valve. [1] - This location is common for innocent murmurs, such as a **Still's murmur** in children. *Soft* - Benign murmurs are characterized by being **soft (grade I-II/VI)**, meaning they are barely audible or easily heard but without a thrill. [1] - A **loud murmur (grade III/VI or higher)**, especially with a palpable thrill, is more indicative of a **pathological condition**.

Q: The treatment of acute myocardial infarction includes which of the following?

Aspirin. ***Aspirin*** - **Aspirin** is a cornerstone of acute myocardial infarction treatment due to its **antiplatelet effects**, which reduce thrombus formation in the coronary arteries [4]. - It works by **irreversibly inhibiting cyclooxygenase-1 (COX-1)**, thereby preventing the synthesis of thromboxane A2, a potent platelet aggregator [4]. *Heparin* - **Heparin** (unfractionated or low molecular weight) is an **anticoagulant** often used adjunctively in acute MI, particularly in patients undergoing percutaneous coronary intervention (PCI) or with concurrent atrial fibrillation [1]. - Its primary role is to **prevent further clot formation** rather than directly dissolving existing clots, making it not the initial, primary treatment for MI itself. *Alteplase* - **Alteplase** is a **fibrinolytic agent** used in acute ST-elevation myocardial infarction (STEMI) to **dissolve existing clots** and restore blood flow [3]. - While effective, it is not universally indicated for *all* acute MI cases and has specific contraindications, making it a secondary rather than primary initial treatment choice in many scenarios when compared to aspirin [2]. *Oral anticoagulants* - **Oral anticoagulants** (e.g., warfarin, direct oral anticoagulants) are primarily used for **long-term prevention** of thromboembolic events, such as in atrial fibrillation or after venous thromboembolism. - They are generally **not used in the immediate acute phase of MI** as the primary treatment due to their slower onset of action and different mechanisms compared to antiplatelet drugs like aspirin.

Q: Pulsus paradoxus is not observed in which of the following conditions?

IPPV. ***IPPV*** - **Intermittent positive pressure ventilation (IPPV)** involves positive pressure delivery of air, which tends to increase intrathoracic pressure. This counteracts the inspiratory fall in intrathoracic pressure that normally accentuates pulsus paradoxus [1]. - In patients on mechanical ventilators, the respiratory variation in intrathoracic pressure is altered, often **attenuating or reversing the normal physiological mechanisms** that lead to pulsus paradoxus [1]. *COPD* - Patients with **severe COPD** often exhibit pulsus paradoxus due to the greatly exaggerated negative intrathoracic pressure generated during inspiration. - The increased **airflow resistance** and **hyperinflation** in COPD lead to extreme swings in intrathoracic pressure, which impedes venous return and left ventricular filling during inspiration. *Cardiac Tamponade* - **Cardiac tamponade** is a classic cause of pulsus paradoxus, where fluid in the pericardial sac compresses the heart, severely restricting ventricular filling. - During inspiration, the increased venous return to the right side of the heart causes the interventricular septum to bulge into the left ventricle, further reducing left ventricular filling and causing a **marked drop in systolic blood pressure**. *Constrictive pericarditis* - Patients with **constrictive pericarditis** often show pulsus paradoxus, although it may be less pronounced than in cardiac tamponade. - The **rigid, thickened pericardium** impairs ventricular filling, and the respiratory variations in filling still impact the transpulmonary gradient, leading to a inspiratory drop in systolic pressure.

Question 1

In the ECG shown below, which drug should be avoided in the management of atrial fibrillation?

Accepted Answer

Adenosine

Answer

Amiodarone

Answer

Diltiazem

Answer

Beta-blocker

Question 2

Which of the following statements regarding the left parasternal lift are NOT true?

Accepted Answer

All of the options

Answer

Synchronous with left ventricular apical impulse.

Answer

Starts in early systole.

Answer

Corresponds to 'V' wave in LA pressure curve.

Question 3

Which of the following statements is true about infective endocarditis in IV drug abusers?

Accepted Answer

Tricuspid valve is most commonly involved

Answer

Candida is a common cause.

Answer

Pulmonary valve is commonly involved

Answer

Staphylococcus aureus is rarely the commonest organism.

Question 4

Intracavitary electrocardiography is a diagnostic aid in which of the following conditions?

Accepted Answer

Ebstein's anomaly of the tricuspid valve

Answer

Tricuspid valve stenosis

Answer

Atrial septal defect

Answer

Ventricular septal defect

Question 5

A 50-year-old man with a history of smoking, hypertension, and chronic exertional angina develops several daily episodes of chest pain at rest compatible with cardiac ischemia. The patient is hospitalized. All the following would be part of an appropriate management plan except one.

Accepted Answer

Lidocaine

Answer

Intravenous heparin

Answer

Aspirin

Answer

Beta-blockers

Question 6

A 59-year-old man with severe myxomatous mitral regurgitation is asymptomatic, with a left ventricular ejection fraction of 45% and an end-systolic diameter index of 2.9 cm/m2. The most appropriate treatment is

Accepted Answer

Mitral valve repair or replacement

Answer

ACE inhibitor therapy

Answer

Digoxin and diuretic therapy

Answer

Observation without intervention

Question 7

A young basketball player with a height of 188 cm and an arm span of 197 cm has a diastolic murmur best heard in the second right intercostal space. The likely cause of the murmur is:

Accepted Answer

AR

Answer

AS

Answer

MR

Answer

Coarctation of the aorta

Question 8

All of the following are features of a benign heart murmur except which of the following?

Accepted Answer

Radiating to the lower chest

Answer

Mid systolic

Answer

Heard at the left sternal area

Answer

Soft

Question 9

The treatment of acute myocardial infarction includes which of the following?

Accepted Answer

Aspirin

Answer

Oral anticoagulants

Answer

Heparin

Answer

Alteplase

Question 10

Pulsus paradoxus is not observed in which of the following conditions?

Accepted Answer

IPPV

Answer

COPD

Answer

Constrictive pericarditis

Answer

Cardiac Tamponade

Cardiology — MCQs

Cardiology — MCQs

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