Cardiology Practice Questions

Q: Assays of which of the following biomarkers is most commonly used in the diagnosis of heart failure?

Brain Natriuretic Peptide (BNP). The diagnosis of heart failure (HF) relies on clinical assessment supported by biomarkers that reflect ventricular wall stress [1]. **Brain Natriuretic Peptide (BNP)** and its inactive cleavage product, **NT-proBNP**, are the gold-standard biomarkers used in clinical practice [3]. **Why BNP is the Correct Answer:** BNP is synthesized primarily by the **ventricular myocardium** in response to increased wall tension, stretch, or pressure overload [3]. It acts as a compensatory hormone by promoting natriuresis, diuresis, and vasodilation to reduce preload and afterload [2]. Its high **negative predictive value** makes it exceptionally useful in the emergency department to rule out HF in patients presenting with acute dyspnea [1]. **Analysis of Incorrect Options:** * **Atrial Natriuretic Peptide (ANP):** Produced mainly by the atria. While elevated in HF, it has a very short half-life (approx. 2 minutes) compared to BNP (approx. 20 minutes) [3], making it clinically impractical for routine assays. * **Endothelin-1 (ET-1):** A potent vasoconstrictor. While levels correlate with the severity of HF and pulmonary hypertension, it is not used for diagnosis due to lack of specificity and standardized testing. * **Adrenomedullin:** A vasodilator peptide. Though it increases in HF, it is not a standard diagnostic tool and lacks the established clinical cut-offs that BNP possesses. **NEET-PG High-Yield Pearls:** * **Cut-off values for Acute HF:** BNP <100 pg/mL or NT-proBNP <300 pg/mL effectively rules out heart failure. * **Neprilysin Inhibitors (Sacubitril):** These drugs prevent the breakdown of BNP. Therefore, in patients on ARNI therapy, **NT-proBNP** must be used for monitoring instead of BNP, as BNP levels will be pharmacologically elevated. * **False Positives:** BNP can be elevated in old age, renal failure, and atrial fibrillation. It is characteristically **lower** in obese patients.

Q: Inoue balloon is used in the treatment of which condition?

Mitral Stenosis. The **Inoue Balloon** is the gold-standard device used for **Percutaneous Transvenous Mitral Commissurotomy (PTMC)**, also known as Balloon Mitral Valvotomy (BMV) [1]. It is specifically designed to treat symptomatic **Mitral Stenosis**, typically of rheumatic origin, provided the valve morphology is favorable (assessed via the Wilkins Score) [1]. **Why it is the correct answer:** The Inoue balloon is a unique, pressure-expandable, multi-stage balloon made of nylon and rubber. It has a "waist" that allows it to be self-centering across the stenotic mitral valve. When inflated, it exerts mechanical force to split the fused commissures, thereby increasing the valve area and relieving the obstruction. **Why other options are incorrect:** * **Atrial Septal Defect (ASD) & Patent Foramen Ovale (PFO):** These are septal defects treated with **occluder devices** (e.g., Amplatzer Septal Occluder) to close the shunt, not balloons to open a valve. * **Mitral Regurgitation:** This is a condition of valvular incompetence [2]. Balloon dilatation would worsen the leak. Treatment usually involves surgical repair/replacement or percutaneous clips (e.g., MitraClip) [2]. **High-Yield Clinical Pearls for NEET-PG:** * **Wilkins Score:** Used to assess suitability for PTMC. It evaluates four parameters: Leaflet mobility, thickening, calcification, and subvalvular thickening. A score **≤ 8** is ideal for the procedure. * **Contraindications for PTMC:** Presence of a left atrial thrombus (risk of stroke) and moderate-to-severe mitral regurgitation [2], [3]. * **Access:** The procedure requires **transseptal puncture** (passing from the right atrium to the left atrium through the fossa ovalis) to reach the mitral valve.

Q: Which of the following physical signs is seen in a patient with severe aortic stenosis?

Delayed peak of systolic murmur. **Explanation:** In **Aortic Stenosis (AS)**, the hallmark physical finding is a crescendo-decrescendo systolic ejection murmur [1]. As the stenosis becomes more **severe**, the pressure gradient across the valve takes longer to reach its maximum, causing the murmur to peak later in systole. This **delayed peak of systolic murmur** (late-peaking) is a reliable indicator of severity, often accompanied by a "pulsus parvus et tardus" (weak and delayed carotid upstroke) [1]. **Analysis of Incorrect Options:** * **A. Opening Snap:** This is a high-pitched diastolic sound characteristic of **Mitral Stenosis** [2], caused by the sudden tensing of the chordae tendineae and stenotic valve leaflets. * **B. Diastolic Rumble:** This describes the low-pitched mid-diastolic murmur of **Mitral Stenosis** or the Austin Flint murmur of Aortic Regurgitation [3]. AS produces a systolic, not diastolic, murmur. * **C. Holosystolic Murmur:** This is typical of **Mitral Regurgitation, Tricuspid Regurgitation, or Ventricular Septal Defect (VSD)**, where the pressure gradient remains constant throughout systole. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of Severe AS:** Angina, Syncope, and Dyspnea (SAD). * **Soft/Absent S2:** In severe AS, the aortic component (A2) becomes soft or disappears because the valve leaflets are too calcified to snap shut [1]. * **Paradoxical Splitting of S2:** Occurs in severe AS because the prolonged left ventricular ejection time causes A2 to occur after P2. * **Gallavardin Phenomenon:** The dissociation between the noisy (musical) component of the AS murmur at the apex and the harsh component at the base, often mimicking mitral regurgitation [1].

Q: A 55-year-old female presented to the ER with sudden onset of shortness of breath along with syncope. Chest X-ray was unremarkable. ECG was done. On examination, some skin lesions were observed. What is the most likely diagnosis in this case?

Sarcoidosis. ***Sarcoidosis*** - **Cardiac sarcoidosis** can present with **complete heart block** causing **syncope** and **shortness of breath**, with **unremarkable chest X-ray** in isolated cardiac involvement. - **Skin manifestations** like **lupus pernio** or **erythema nodosum** are characteristic features that support the diagnosis. *Carney syndrome* - A rare **genetic disorder** characterized by **cardiac myxomas**, **skin pigmentation**, and **endocrine tumors**. - Syncope would be due to **myxoma obstruction**, not **conduction abnormalities**, and lacks the typical skin lesions of sarcoidosis. *Hypothyroidism* - Causes **bradycardia** and **fatigue** but rarely leads to **complete heart block** or **acute syncope**. - Associated with **myxedematous skin changes** (dry, coarse skin), not the inflammatory skin lesions described. *SLE* - Can cause **pericarditis** and **Libman-Sacks endocarditis** but rarely presents with **isolated heart block**. - **Malar rash** and **discoid lesions** are typical, but the acute presentation with syncope is less characteristic.

Q: Carcinoid syndrome produces valvular disease primarily involving which valves?

Tricuspid valves. **Explanation:** Carcinoid heart disease occurs in approximately 50% of patients with systemic carcinoid syndrome. It is characterized by the deposition of **fibrous, plaque-like endocardial thickening** on the valves and endocardial surfaces. **Why Tricuspid Valve is Correct:** The primary mediators of carcinoid syndrome (serotonin, bradykinin, and histamine) are released by neuroendocrine tumors, typically from the GI tract [1]. These substances reach the **right side of the heart** first via the systemic circulation. Serotonin induces fibroblast proliferation, leading to **Tricuspid Regurgitation** (most common) and Pulmonary Stenosis [1]. The valves become thickened, shortened, and rigid. **Why Other Options are Incorrect:** * **Mitral and Aortic Valves (Left-sided):** These are generally **spared** because the lungs contain high concentrations of **Monoamine Oxidase (MAO)**. As blood passes through the pulmonary circulation, MAO inactivates serotonin and other vasoactive substances before they can reach the left atrium and ventricle. * **Pulmonary Valve:** While the pulmonary valve is frequently involved (usually causing stenosis), the **tricuspid valve** is the most commonly and severely affected structure in carcinoid heart disease. **High-Yield Clinical Pearls for NEET-PG:** * **Pathognomonic Feature:** Fibrous white plaques on the endocardium. * **Left-sided involvement occurs ONLY if:** 1. There is a **Right-to-Left shunt** (e.g., Patent Foramen Ovale). 2. The primary tumor is in the **Lungs** (bronchial carcinoid), bypassing pulmonary metabolism. * **Biomarker:** Elevated 24-hour urinary **5-HIAA** (5-Hydroxyindoleacetic acid). * **Management:** Somatostatin analogues (Octreotide) to control symptoms and surgical valve replacement for advanced heart failure.

Question 1

Assays of which of the following biomarkers is most commonly used in the diagnosis of heart failure?

Accepted Answer

Brain Natriuretic Peptide (BNP)

Answer

Atrial Natriuretic Peptide (ANP)

Answer

Endothelin-1 (ET-1)

Answer

Adrenomedullin

Question 2

Inoue balloon is used in the treatment of which condition?

Accepted Answer

Mitral Stenosis

Answer

Atrial Septal Defect (ASD)

Answer

Mitral Regurgitation

Answer

Patent Foramen Ovale (PFO)

Question 3

Ventricular ectopic beats are represented by which of the following findings?

Accepted Answer

Irregular RR interval

Answer

Incomplete compensatory pause

Answer

A.V. dissociation

Answer

Presence of fusion beat

Question 4

In a hospital cardiac care unit, there are three patients with different cardiac conditions: a 52-year-old man with dilated cardiomyopathy, an 18-year-old girl with mitral valve prolapse, and a 30-year-old man with infective endocarditis of the mitral valve. Which of the following features do all these patients most likely share?

Accepted Answer

Risk of systemic thromboembolism

Answer

Decreased compliance

Answer

Depressed myocardial contractility

Answer

Infectious etiology

Question 5

Which of the following physical signs is seen in a patient with severe aortic stenosis?

Accepted Answer

Delayed peak of systolic murmur

Answer

Opening snap

Answer

Diastolic rumble

Answer

Holosystolic murmur

Question 6

A 55-year-old female presented to the ER with sudden onset of shortness of breath along with syncope. Chest X-ray was unremarkable. ECG was done. On examination, some skin lesions were observed. What is the most likely diagnosis in this case?

Accepted Answer

Sarcoidosis

Answer

Carney syndrome

Answer

Hypothyroidism

Answer

SLE

Question 7

A 68-year-old man who has had a recent syncopal episode is hospitalized with congestive heart failure. His blood pressure is 160/80 mmHg. His pulse rate is 80 beats per minute, and there is a grade III/IV harsh systolic murmur. An echocardiogram shows a disproportionately thickened ventricular septum and systolic anterior motion of the mitral valve. Which of the following findings would most likely be present in this man?

Accepted Answer

Decrease of the murmur with hand grip.

Answer

Radiation of the murmur to the neck.

Answer

Delayed carotid upstroke.

Answer

Reduced left ventricular ejection fraction.

Question 8

A 42-year-old man presents with central, crushing chest pain that radiates to the jaw. The pain occurred while jogging and was alleviated with rest. The ECG is normal. What is the most likely diagnosis?

Accepted Answer

Angina pectoris

Answer

Acute Pericarditis

Answer

STEMI

Answer

NSTEMI

Question 9

A 42-year-old man presents with dizziness on standing, and his systolic blood pressure falls by 50 mm Hg. Which of the following would be most appropriate?

Accepted Answer

Salmeterol

Answer

Gradual stockings and compressions

Answer

Isoproterenol

Answer

Fludrocortisone

Question 10

Carcinoid syndrome produces valvular disease primarily involving which valves?

Accepted Answer

Tricuspid valves

Answer

Pulmonary valves

Answer

Mitral valve

Answer

Aortic valve

Cardiology — MCQs

Cardiology — MCQs

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