Cardiology Practice Questions

Q: Which of the following is not a symptom of cardiac failure?

Non-pulsatile elevation of JVP. ***Non-pulsatile elevation of JVP*** - In cardiac failure, **JVP is elevated but remains pulsatile**, showing normal **a, c, and v waves** from the transmitted cardiac cycle. - **Non-pulsatile JVP elevation** is characteristic of **superior vena cava (SVC) syndrome**, where complete venous obstruction blocks pulsation transmission, not cardiac failure. *Right hypochondriac pain* - This **is a symptom** of **right-sided heart failure** due to **hepatic congestion** and stretching of **Glisson's capsule**. - Results from **passive liver engorgement** secondary to elevated right atrial pressure and systemic venous congestion. *Orthopnea* - Classic symptom of **left-sided heart failure** characterized by breathlessness when lying flat due to **pulmonary venous congestion**. - Worsens in supine position as **venous return increases** and is relieved by sitting upright. *Paroxysmal nocturnal dyspnea* - Sudden severe **shortness of breath** that wakes patients from sleep, typically **1-2 hours** after falling asleep. - Caused by **delayed resorption of peripheral edema** and increased venous return while supine, leading to acute **pulmonary congestion**.

Q: Mitral stenosis murmur corresponds to which wave of ECG?

P wave. ***P wave*** - The **P wave** on the ECG represents **atrial depolarization** and precedes atrial contraction (atrial systole) [3]. - In **mitral stenosis (MS)**, the characteristic presystolic accentuation (a later component of the diastolic murmur) is caused by the force of atrial contraction just prior to the QRS complex, correlating with the P wave [4]. ***QRS complex*** - The **QRS complex** represents **ventricular depolarization** and precedes ventricular contraction (ventricular systole) [3]. - The mitral stenosis murmur is a **diastolic murmur**; it occurs after the T wave and ends before the QRS complex (or is accentuated just before it by atrial kick) [1], [4]. ***T wave*** - The **T wave** represents **ventricular repolarization** [3]. - The T wave marks the end of systole; the mitral stenosis murmur begins *after* the T wave, during the period of isovolumetric relaxation and subsequent rapid ventricular filling [2]. ***ST segment*** - The **ST segment** represents the period between ventricular depolarization and repolarization (plateau phase of the action potential). - This segment is part of systole, whereas the mitral stenosis murmur is strictly a **diastolic event** [1], [4].

Q: A patient with recurrent episodes of PSVT (Paroxysmal Supraventricular Tachycardia) is being considered for long-term prophylactic therapy to prevent future episodes. Which of the following is the most appropriate preventive treatment?

Oral Verapamil. ***Oral Verapamil*** - This is a non-dihydropyridine **Calcium Channel Blocker** that effectively slows conduction and increases refractoriness in the **AV node**. - It is a standard oral medication used for the **long-term prevention (prophylaxis)** of recurrent PSVT, especially in cases of AVNRT or AVRT. *IV lignocaine* - Lignocaine (Lidocaine) is a **Class IB antiarrhythmic** primarily used to treat and prevent **ventricular arrhythmias** (premature ventricular contractions, VT). - It is generally ineffective for chronic prophylaxis of supraventricular tachycardias like PSVT. *IV Adenosine* - **Adenosine** is the preferred drug for the **acute termination** of PSVT due to its potent, transient block of the AV node (half-life of <10 seconds). - It has an extremely short half-life, making it unsuitable for a chronic, **oral preventive regimen**. *Oral Nifedipine* - Nifedipine is a **dihydropyridine Calcium Channel Blocker** primarily acting as a **peripheral vasodilator**. - It has minimal effects on the **AV nodal conduction** properties required for PSVT prophylaxis and is therefore not used for this purpose.

Q: A patient presents with palpitations and an irregularly irregular pulse. He presents within 2 hours of symptom onset, and has no history of diabetes or other comorbidities. What is the most appropriate initial management?

Cardioversion. ***Cardioversion*** - Since the patient presented within **<12 hours** of symptom onset (paroxysmal AF) and is hemodynamically stable, particularly without comorbidities, urgent rhythm control via **cardioversion (electrical or pharmacological)** is the optimal management to restore sinus rhythm [1]. - The very early presentation (within 2 hours) and the absence of significant comorbidities suggest a good chance for maintenance of sinus rhythm without immediate concern for complex thrombus formation. *TEE for starting anticoagulation* - **Transesophageal echocardiography (TEE)** is performed to rule out left atrial appendage thrombus before cardioversion if the duration of AF is **unknown or >48 hours**, or if anticoagulation has been inadequate (less than 3 weeks). - In this case, since the onset is clearly 48 hours** ago. - For new-onset AF with a short duration, **rhythm control** (cardioversion) is preferred [1]. *Wait and watch* - **Wait and watch** is inappropriate as **atrial fibrillation (AF)** is associated with a high risk of systemic embolization and stroke, necessitating prompt management (either rhythm or rate control). - Immediate intervention is required to prevent complications and potentially restore sinus rhythm, especially given the very early presentation.

Q: A patient with paroxysmal supraventricular tachycardia (PSVT) requires treatment for prophylaxis. Which drug is appropriate?

Oral verapamil. ***Verapamil*** - It is an oral **non-dihydropyridine calcium channel blocker** commonly used for long-term **prophylaxis** of recurrent PSVT (AVNRT/AVRT) by slowing conduction through the AV node [1], [2]. - It is effective for reducing the frequency of episodes and achieving chronic **rate and rhythm control** in stable patients [1]. *IV adenosine* - Adenosine is the drug of choice for the **acute termination** of PSVT due to its rapid onset and extremely short half-life, making it unsuitable for chronic long-term **prophylaxis** [2]. - It works by transiently blocking the **AV node** conduction [2]. *IV esmolol* - Esmolol is an ultra-short-acting **beta-blocker** administered intravenously, primarily used for **acute control** of heart rate or rhythm in emergency settings [3]. - Since the requirement is for prophylaxis, an oral formulation (e.g., oral metoprolol) would be preferred over an **intravenous agent** [3]. *Oral phenytoin* - Phenytoin is mainly an anti-epileptic and is historically reserved for the treatment of **digitalis-induced ventricular arrhythmias**. - It is **not a standard or primary agent** recommended by current guidelines for the long-term prophylactic management of typical non-digitalis-induced PSVT.

Q: The lead of ECG marked as $X$ is called:

Lewis lead. ***Lewis lead*** - This image displays the placement of electrodes for a **Lewis lead** ECG, used to enhance the detection of **atrial activity**, particularly for P waves. - The Lewis lead involves placing the right arm electrode (usually from a standard ECG setup) at the **right sternal border in the second intercostal space**, and the left arm electrode at the **right parasternal border in the fourth intercostal space**. *V4R* - **V4R** is a right-sided precordial lead used to detect **right ventricular infarction** and is placed in the fifth intercostal space at the right midclavicular line. - The electrode placement shown in the image is not consistent with V4R. *aVR* - **aVR** is an augmented unipolar limb lead that records electrical activity from the **right arm** relative to the average of the left arm and left leg electrodes. - It is not a chest lead placement, and therefore does not correspond to the image. *V_{a}* - **V_{a}** is not a standard or recognized ECG lead designation in clinical practice. - The commonly used precordial leads are denoted as V1 through V6.

Q: A 60-year-old hypertension patient presents with palpitations and pre-syncope. ECG was done. All drugs can be used for management of this condition except:

Adenosine. ***Adenosine*** - The ECG shows **atrial fibrillation with rapid ventricular response** and evidence of **pre-excitation** (short PR interval, delta wave), suggesting **Wolff-Parkinson-White (WPW) syndrome** complicated by atrial fibrillation. - Adenosine is **absolutely contraindicated** in AF with WPW syndrome because it causes profound AV nodal blockade, forcing all conduction down the accessory pathway, which can precipitate **life-threatening ventricular fibrillation**. - Among AV nodal blockers, **adenosine poses the greatest risk** due to its rapid, complete AV nodal blockade and is the classic teaching example of drugs to avoid in this condition. *Diltiazem* - **Calcium channel blockers** like diltiazem should generally be avoided in AF with WPW because they block the AV node and can worsen conduction via the accessory pathway, potentially leading to VF. - However, their effect is less abrupt than adenosine, making them somewhat less immediately dangerous. *Esmolol* - **Beta-blockers** like esmolol should also be avoided in AF with WPW syndrome because they block the AV node and can increase conduction through the accessory pathway. - Like calcium channel blockers, the risk is real but less catastrophic than with adenosine. *Amiodarone* - Amiodarone is a **Class III antiarrhythmic** that **can be safely used** for rhythm control in AF with WPW syndrome. - Unlike pure AV nodal blockers, it affects **both the AV node and accessory pathway**, helping to slow conduction through both routes without preferentially shunting impulses down the dangerous accessory pathway. - It is considered appropriate for pharmacological management of this condition.

Question 1

Which of the following is not a symptom of cardiac failure?

Accepted Answer

Non-pulsatile elevation of JVP

Answer

Right hypochondriac pain

Answer

Orthopnea

Answer

Paroxysmal nocturnal dyspnea

Question 2

Mitral stenosis murmur corresponds to which wave of ECG?

Accepted Answer

P wave

Answer

QRS complex

Answer

ST segment

Answer

T wave

Question 3

A 58-year-old male presents to a PHC for a routine check-up. His blood pressure readings on two separate occasions are 148 / 90 mmHg and 152 / 96 mmHg. He is asymptomatic and has no known comorbidities. What is the most appropriate next step in management according to current hypertension guidelines?

Accepted Answer

Start Amlodipine 5 mg once daily and advise follow-up after a month

Answer

Initiate treatment only if BP exceeds 160 / 100 mmHg

Answer

Start the patient on IV anti-hypertensive drugs

Answer

Refer to a higher center for further evaluation

Question 4

A patient with recurrent episodes of PSVT (Paroxysmal Supraventricular Tachycardia) is being considered for long-term prophylactic therapy to prevent future episodes. Which of the following is the most appropriate preventive treatment?

Accepted Answer

Oral Verapamil

Answer

IV Adenosine

Answer

Oral Nifedipine

Answer

IV lignocaine

Question 5

A patient presents with palpitations and an irregularly irregular pulse. He presents within 2 hours of symptom onset, and has no history of diabetes or other comorbidities. What is the most appropriate initial management?

Accepted Answer

Cardioversion

Answer

Control ventricular rate with verapamil

Answer

TEE for starting anticoagulation

Answer

Wait and watch

Question 6

A 30-year-old man with 6 month past history of PND and SOB. On examination, JVP is elevated with irregularly irregular pulse and tender hepatomegaly and MDM. past medical history of ARF. Which of the following is not seen in this patient?

Accepted Answer

Presystolic accentuation of mid-diastolic murmur is hallmark feature

Answer

Right heart failure

Answer

Absent a wave in JVP

Answer

Patient has increased risk of embolic stroke

Question 7

A patient with paroxysmal supraventricular tachycardia (PSVT) requires treatment for prophylaxis. Which drug is appropriate?

Accepted Answer

Oral verapamil

Answer

IV esmolol

Answer

Oral phenytoin

Answer

IV adenosine

Question 8

The lead of ECG marked as $X$ is called:

Accepted Answer

Lewis lead

Answer

V4R

Answer

aVR

Answer

V_{a}

Question 9

A 45-year-old patient of hypertension presents with chest pain radiating to inter-scapular area. ECG shows ST segment elevation and elevated cardiac biomarkers. Thrombolysis was initiated but patient did not improve. Cardiac MRI was performed but patient expired thereafter. All are true about the condition shown and its treatment except:

Accepted Answer

The condition progressed to produce coronary artery dissection

Answer

Thrombolysis should not have been started in the patient

Answer

Esmolol would have reduced the propagation of condition

Answer

Sodium nitroprusside would have controlled resultant hypertension

Question 10

A 60-year-old hypertension patient presents with palpitations and pre-syncope. ECG was done. All drugs can be used for management of this condition except:

Accepted Answer

Adenosine

Answer

Diltiazem

Answer

Esmolol

Answer

Amiodarone

Cardiology — MCQs

Cardiology — MCQs

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