Cardiology Practice Questions

Q: What is the most common cause of Left Ventricular Hypertrophy?

Hypertension. **Explanation:** **1. Why Hypertension is the Correct Answer:** Left Ventricular Hypertrophy (LVH) is a compensatory response to increased **afterload**. In systemic hypertension, the left ventricle must generate higher pressure to overcome the increased systemic vascular resistance [2]. According to **Laplace’s Law** (Wall Stress = Pressure × Radius / 2 × Wall Thickness), the myocardium undergoes **concentric hypertrophy** (addition of sarcomeres in parallel) to normalize wall stress. While several conditions cause LVH, hypertension is the most common cause in the general population due to its high global prevalence [1], [3]. **2. Analysis of Incorrect Options:** * **B. Aortic Stenosis:** This is a classic cause of pressure-overload LVH [2]. While it produces significant hypertrophy, it is far less common epidemiologically than systemic hypertension. * **C. Aortic Regurgitation:** This causes **volume overload**, leading to **eccentric hypertrophy** [2] (ventricular dilation with proportional wall thickening; sarcomeres added in series). It is not the most common cause of generalized LVH. * **D. Hypertrophic Obstructive Cardiomyopathy (HOCM):** This is a genetic disorder characterized by asymmetrical septal hypertrophy. It is a primary myocardial disease and is rare compared to secondary causes like hypertension. **3. Clinical Pearls for NEET-PG:** * **ECG Criteria:** The most common criteria used is the **Sokolow-Lyon Index** (S in V1 + R in V5 or V6 > 35 mm). * **Gold Standard Investigation:** Echocardiography (more sensitive than ECG). * **Concentric vs. Eccentric:** Pressure overload (HTN, AS) leads to concentric hypertrophy; Volume overload (AR, MR) leads to eccentric hypertrophy [2]. * **Reverse Remodeling:** ACE inhibitors and ARBs are the drugs of choice to help regress hypertensive LVH.

Q: A 60-year-old woman presents with a murmur suggestive of mitral stenosis and an echocardiography confirmed a mass attached to the fossa ovalis of the left atrial septum. What is the most likely diagnosis?

Cardiac myxoma. ### Explanation **Correct Answer: A. Cardiac Myxoma** **Why it is correct:** Cardiac myxoma is the most common primary cardiac tumor in adults. Approximately **75-80% occur in the left atrium**, typically attached by a pedicle to the **interatrial septum at the fossa ovalis**. The clinical presentation often mimics **mitral stenosis** because the pedunculated mass can physically obstruct the mitral valve orifice during diastole (the "wrecking ball" effect) [3]. This produces a mid-diastolic murmur [1] and sometimes a characteristic "tumor plop" heard on auscultation [3]. **Why the other options are incorrect:** * **B. Endocarditis:** Usually presents with fever, new-onset regurgitant murmurs (not stenotic), and vegetations on valve leaflets rather than a large mass on the septum [2]. * **C. Lymphoma:** Primary cardiac lymphomas are extremely rare and typically involve the right heart or cause pericardial effusions rather than a septal mass mimicking mitral stenosis. * **D. Metastatic cancer:** While more common than primary tumors, metastases (e.g., from lung, breast, or melanoma) usually involve the pericardium or myocardium and rarely present as a solitary pedunculated mass on the fossa ovalis. **NEET-PG High-Yield Pearls:** * **Triad of Myxoma:** Constitutional symptoms (fever, weight loss due to IL-6 production), Embolic phenomena, and Obstructive symptoms (mimicking mitral stenosis). * **Position Dependency:** Symptoms and murmurs may change with the patient's body position. * **Carney Complex:** An autosomal dominant syndrome (PRKAR1A mutation) featuring atrial myxomas, skin pigmentation (lentigines), and endocrine overactivity. * **Diagnosis:** Echocardiography is the gold standard for initial identification [2].

Q: Wide pulse pressure is seen in which of the following conditions?

Beri beri. Pulse pressure is the difference between systolic (SBP) and diastolic blood pressure (DBP). A wide pulse pressure occurs when there is either an increase in stroke volume (elevated SBP) or a decrease in peripheral vascular resistance (lowered DBP) [1]. **Why Beriberi is Correct:** Wet Beriberi (Thiamine/Vitamin B1 deficiency) is a classic cause of high-output heart failure. It leads to systemic vasodilation and the formation of multiple small arteriovenous shunts. This significantly reduces peripheral vascular resistance (lowering DBP) and increases venous return, which boosts stroke volume (raising SBP). The result is a characteristically wide pulse pressure. **Why Incorrect Options are Wrong:** * **Cardiac Tamponade:** Causes a narrow pulse pressure [2]. Fluid in the pericardial sac restricts ventricular filling, leading to a sharp drop in stroke volume and SBP [2]. * **Diarrhea:** Leads to hypovolemia. Reduced blood volume decreases stroke volume and triggers compensatory vasoconstriction, resulting in a narrow pulse pressure. * **Aortic Stenosis:** Known for a "Pulsus Parvus et Tardus" (small and slow pulse). The narrowed valve orifice limits the stroke volume and slows the rate of ejection, leading to a narrow pulse pressure [3]. **High-Yield Clinical Pearls for NEET-PG:** * **Other causes of Wide Pulse Pressure:** Aortic Regurgitation (most common cause), Thyrotoxicosis, Anemia, Fever, and Patent Ductus Arteriosus (PDA) [1]. * **Water-Hammer Pulse:** Often associated with wide pulse pressure conditions, particularly Aortic Regurgitation [1]. * **Narrow Pulse Pressure:** Seen in Heart Failure, Shock, and Mitral Stenosis.

Q: Torsade de pointes is caused by:

Hypomagnesemia. **Explanation:** **Torsades de Pointes (TdP)** is a specific form of polymorphic ventricular tachycardia characterized by a "twisting of the points" around the isoelectric line. It occurs in the setting of a **prolonged QT interval** [1], [2]. **Why Hypomagnesemia is correct:** Magnesium acts as a natural calcium channel blocker and is essential for the function of the Na+/K+-ATPase pump. **Hypomagnesemia** (and hypokalemia) leads to impaired repolarization of cardiac myocytes, which prolongs the action potential duration and the QT interval [3]. This creates a substrate for **Early After-Depolarizations (EADs)**. When these EADs reach a threshold, they trigger the rapid, irregular firing characteristic of TdP. Consequently, intravenous Magnesium Sulfate is the first-line treatment for TdP, even in patients with normal serum magnesium levels. **Why the other options are incorrect:** * **Hypermagnesemia:** High magnesium levels actually stabilize the cardiac membrane and are used to *treat* arrhythmias; they do not cause TdP. * **Metabolic Acidosis/Alkalosis:** While severe pH imbalances can affect cardiac excitability, they are not primary or classic triggers for TdP. TdP is specifically linked to electrolyte disturbances (Hypo-K, Hypo-Mg, Hypo-Ca) and drugs that prolong the QT interval. **High-Yield Clinical Pearls for NEET-PG:** * **Drug-induced TdP (ABCDE):** **A**ntiarrhythmics (Class IA, III), **B**iotics (Macrolides, Fluoroquinolones), **C**isapride (Antipsychotics/Antiemetics), **D**epressants (TCAs), **E**lectrolytes (Hypo-K, Hypo-Mg). * **Congenital Long QT Syndromes:** Romano-Ward (Autosomal Dominant, pure cardiac) and Jervell and Lange-Nielsen (Autosomal Recessive, cardiac + sensorineural deafness) [2]. * **Management:** IV Magnesium Sulfate is the drug of choice. If refractory, use overdrive pacing or Isoproterenol to increase heart rate (which shortens the QT interval). Avoid Class IA and III antiarrhythmics.

Q: Which of the following is the preferred antiarrhythmic agent in a patient with cardiac arrest?

Amiodarone. **Explanation:** In the management of cardiac arrest due to **Shockable Rhythms** (Ventricular Fibrillation or Pulseless Ventricular Tachycardia), **Amiodarone** is the first-line antiarrhythmic agent according to the current ACLS (Advanced Cardiovascular Life Support) guidelines. **Why Amiodarone is Correct:** Amiodarone is a Class III antiarrhythmic that acts by blocking potassium channels (prolonging repolarization), but it also possesses Class I, II, and IV properties. In cardiac arrest, it is preferred because clinical trials (like the ALIVE trial) demonstrated that it improves the rate of **ROSC (Return of Spontaneous Circulation)** and survival to hospital admission compared to placebo or lidocaine. It is typically administered as a 300 mg IV/IO bolus after the third unsuccessful shock. **Why Other Options are Incorrect:** * **Lidocaine:** While Lidocaine is an acceptable alternative if Amiodarone is unavailable, it is no longer the primary choice. It is a Class Ib agent that specifically targets ischemic sodium channels. * **Procainamide:** This Class Ia agent is used for stable wide-complex tachycardia. It is not used in cardiac arrest because it requires slow infusion and can cause significant hypotension. * **Atropine:** Previously used for asystole/PEA, it was removed from the cardiac arrest algorithm in 2010 as it showed no survival benefit. It is now primarily used for symptomatic bradycardia. **High-Yield NEET-PG Pearls:** * **Drug of Choice for VF/pVT:** Amiodarone (1st line), Lidocaine (2nd line). * **Amiodarone Side Effects:** Pulmonary fibrosis, thyroid dysfunction (contains iodine), and corneal microdeposits. * **Amiodarone in WPW Syndrome:** It is the drug of choice for stable patients with WPW and atrial fibrillation. * **Maintenance:** After ROSC, an infusion of the successful antiarrhythmic is often started.

Q: A double apical impulse is seen in which condition?

Hypertrophic Obstructive Cardiomyopathy (HOCM). ### Explanation **Correct Answer: A. Hypertrophic Obstructive Cardiomyopathy (HOCM)** In HOCM, the double apical impulse (also known as a **bifid impulse**) occurs due to two distinct mechanical events felt during systole [2]: 1. **First Component:** The initial forceful contraction of the hypertrophied left ventricle. 2. **Second Component:** A sudden interruption of ventricular outflow caused by **Systolic Anterior Motion (SAM)** of the mitral valve against the thickened septum. This creates a "midsystolic dip," followed by a second pressure peak as the ventricle continues to contract against the obstruction. *Note: If a forceful atrial contraction (S4) is also palpable, it can result in a triple apical impulse.* **Why the other options are incorrect:** * **B. Cardiac Tamponade:** The apex beat is typically **faint or impalpable** due to the insulating effect of the surrounding pericardial fluid. * **C. Aortic Regurgitation:** Characterized by a **hyperdynamic (volume-overload)** apex beat that is displaced laterally and inferiorly, but it remains a single, forceful thrust [1] [3]. * **D. Pulmonary Hypertension:** This leads to right ventricular hypertrophy, which typically manifests as a **left parasternal heave**, not a double apical impulse [1]. **NEET-PG High-Yield Pearls for HOCM:** * **Triple Ripple:** A palpable S4 + Double Systolic Impulse (pathognomonic for HOCM) [2]. * **Pulse:** Characterized by **pulsus bisferiens** (a double-peaked arterial pulse). * **Murmur:** A harsh systolic ejection murmur that **increases** with Valsalva or standing (decreased preload) and **decreases** with squatting or handgrip (increased afterload/preload) [2]. * **ECG:** Often shows "dagger-like" Q waves in lateral leads (I, aVL, V5-V6).

Q: An ankle-brachial index (ABI) that suggests increased risk of myocardial infarction would be:

<0.9. The **Ankle-Brachial Index (ABI)** is a non-invasive tool used to screen for Peripheral Arterial Disease (PAD). It is calculated by dividing the higher systolic blood pressure at the ankle (tibialis posterior or dorsalis pedis) by the higher systolic blood pressure in the arm. **Why <0.9 is correct:** An **ABI <0.9** is the diagnostic threshold for PAD. [1] PAD is considered a "coronary artery disease equivalent." Because atherosclerosis is a systemic process, its presence in the lower extremities indicates widespread vascular damage. [1] Patients with an ABI 0.9 (Option C):** An ABI between **0.91 and 1.30** is considered normal. Values in this range indicate healthy blood flow and a lower risk of cardiovascular events. * **>0.6 (Option D):** This range includes normal values (0.9–1.3), which would not suggest an increased risk of MI. **High-Yield Clinical Pearls for NEET-PG:** * **ABI >1.4:** Suggests non-compressible, calcified vessels (commonly seen in **Diabetes Mellitus** and Chronic Kidney Disease). In such cases, a **Toe-Brachial Index (TBI)** should be performed. * **ABI 0.4–0.7:** Associated with moderate PAD and intermittent claudication. [1] * **ABI <0.4:** Associated with severe PAD, rest pain, and critical limb ischemia. [1] * **Gold Standard:** While ABI is the best screening tool, **Digital Subtraction Angiography (DSA)** remains the gold standard for anatomical mapping before intervention.

Question 1

What is the most common cause of Left Ventricular Hypertrophy?

Accepted Answer

Hypertension

Answer

Aortic Stenosis

Answer

Aortic Regurgitation

Answer

Hypertrophic Obstructive Cardiomyopathy (HOCM)

Question 2

A 60-year-old woman presents with a murmur suggestive of mitral stenosis and an echocardiography confirmed a mass attached to the fossa ovalis of the left atrial septum. What is the most likely diagnosis?

Accepted Answer

Cardiac myxoma

Answer

Endocarditis

Answer

Lymphoma

Answer

Metastatic cancer to the heart

Question 3

Wide pulse pressure is seen in which of the following conditions?

Accepted Answer

Beri beri

Answer

Cardiac tamponade

Answer

Diarrhea

Answer

Aortic stenosis

Question 4

Torsade de pointes is caused by:

Accepted Answer

Hypomagnesemia

Answer

Hypermagnesemia

Answer

Metabolic acidosis

Answer

Metabolic alkalosis

Question 5

Which of the following is the preferred antiarrhythmic agent in a patient with cardiac arrest?

Accepted Answer

Amiodarone

Answer

Lidocaine

Answer

Procainamide

Answer

Atropine

Question 6

A double apical impulse is seen in which condition?

Accepted Answer

Hypertrophic Obstructive Cardiomyopathy (HOCM)

Answer

Cardiac tamponade

Answer

Aortic regurgitation

Answer

Pulmonary hypertension

Question 7

A 32-year-old carpenter presents with a history of recurrent chest pain. Sublingual nitroglycerin is prescribed and advised to be taken at the onset of pain. Two weeks later, the patient reports increased chest pain intensity upon taking nitroglycerin. What is the most likely diagnosis?

Accepted Answer

Hypertrophic obstructive cardiomyopathy

Answer

Aortic regurgitation

Answer

Aortic dissection

Answer

Aortic aneurysm

Question 8

An ankle-brachial index (ABI) that suggests increased risk of myocardial infarction would be:

Accepted Answer

<0.9

Answer

<0.6

Answer

>0.9

Answer

>0.6

Question 9

Radiofemoral delay is characteristic of which of the following conditions?

Accepted Answer

Coarctation of the aorta

Answer

Patent ductus arteriosus

Answer

Aortic dissection

Answer

Takayasu's arteritis

Question 10

Which one of the following is an absolute contraindication to the use of a thrombolytic agent in the setting of an acute anterior wall myocardial infarction?

Accepted Answer

History of cerebrovascular accident with hemiparesis one month ago

Answer

Diabetic retinopathy

Answer

Patient's age more than 70 years

Answer

Patient is on warfarin for atrial fibrillation with INR ratio 1.8

Cardiology — MCQs

Cardiology — MCQs

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