Cardiology Practice Questions

Q: All of the following are the causes of High output cardiac failure, except?

Cor pulmonale. ***Cor pulmonale*** - **Cor pulmonale** is **right-sided heart failure** [1] caused by **pulmonary hypertension**, which is typically a low-output state unless accompanied by other contributing factors. - While it affects cardiac function, it fundamentally involves increased pulmonary vascular resistance leading to ventricular dysfunction, not an increase in **cardiac output**. *Systemic AV shunt* - A **systemic AV shunt** can cause high-output heart failure by diverting a significant volume of blood directly from the arterial to the venous system, bypassing the capillary beds. - This significantly **increases venous return** and **cardiac preload**, requiring the heart to pump more blood to maintain adequate systemic perfusion. *Beri beri* - **Beri-beri heart disease**, caused by severe **thiamine (vitamin B1) deficiency**, leads to high-output cardiac failure due to **peripheral vasodilation**. - This vasodilation markedly **reduces systemic vascular resistance**, increasing venous return and necessitating a higher cardiac output to maintain blood pressure. *Anemia* - **Severe anemia** causes high-output cardiac failure because the reduced oxygen-carrying capacity of the blood forces the heart to significantly **increase cardiac output** to meet the body's metabolic demands. - This compensatory mechanism involves both an **increased heart rate** and **stroke volume** to ensure adequate tissue oxygenation despite lower hemoglobin levels.

Q: Which of the following describes aortic regurgitation murmur?

Diastolic murmur. ***Diastolic murmur*** - Aortic regurgitation occurs when the **aortic valve does not close completely**, leading to blood flowing back into the **left ventricle during diastole** [1]. - This backflow of blood during the **relaxation phase** of the heart creates the characteristic diastolic murmur [1]. *Ejection systolic murmur* - This murmur type is typically heard during **systole** and is associated with conditions like **aortic stenosis**, where there is turbulent flow across a narrowed aortic valve during ejection [3]. - It does not describe the sound of blood flowing back into the ventricle during **diastole**, which characterizes aortic regurgitation. *Ventricular contraction* - **Ventricular contraction** occurs during **systole** and is the mechanism by which blood is ejected from the ventricles [2]. - While related to cardiac cycle, it does not directly describe the timing or nature of the murmur caused by aortic regurgitation. *Systolic murmur* - A **systolic murmur** is heard when the ventricles contract, such as in conditions like **aortic stenosis** or **mitral regurgitation** [3]. - Aortic regurgitation is specifically a **diastolic event** as blood leaks back into the left ventricle during ventricular relaxation [1].

Q: Identify the ECG given below?

Torsades de pointes. ***Torsades de pointes*** - The ECG shows a polymorphic ventricular tachycardia where the **QRS complexes appear to twist around the baseline**, a classic feature of Torsades de pointes. - This condition is often associated with **QT prolongation**, which is evident in some of the strips preceding the tachyarrhythmia. *Viral myocarditis* - While viral myocarditis can lead to various ECG abnormalities, it typically doesn't present with this specific **polymorphic ventricular tachycardia** morphology. - Common ECG findings in myocarditis include non-specific ST-T wave changes, sinus tachycardia, or conduction blocks, rather than the characteristic "twisting" pattern seen here. *Cardiac tamponade* - Cardiac tamponade is characterized by **electrical alternans** (alternating QRS amplitude), low voltage, and sinus tachycardia on ECG. - It does not cause a polymorphic ventricular tachycardia with the appearance of QRS complexes twisting around the baseline. *Pericarditis* - Pericarditis typically presents with **diffuse ST-segment elevation** (often concave up) and PR-segment depression. - It does not manifest as a polymorphic ventricular tachycardia like Torsades de pointes.

Q: What is the correct order for cardiac auscultation on the left side, from superior to inferior? a. Pulmonary b. Tricuspid c. Mitral

a>b>c (Pulmonary > Tricuspid > Mitral). **a>b>c (Pulmonary > Tricuspid > Mitral)** - This order accurately reflects the anatomical positions of the **auscultation points** on the left side of the chest, moving from the superior aspect (second intercostal space) down to the inferior aspect (fifth intercostal space). - The **pulmonary area** is auscultated at the second left intercostal space, the **tricuspid area** at the fourth or fifth left intercostal space near the sternum, and the **mitral (apical) area** at the fifth left intercostal space at the midclavicular line [1]. *c>b>a (Mitral > Tricuspid > Pulmonary)* - This order is incorrect as it places the **mitral area** (inferior) superior to the **tricuspid** and **pulmonary areas**, which contradicts the anatomical arrangement for auscultation. - Auscultating in this sequence would involve moving from an inferior left position upwards, which is not the standard superior-to-inferior left-sided auscultation approach. *b>a>c (Tricuspid > Pulmonary > Mitral)* - This order is incorrect because it places the **tricuspid area** superior to the **pulmonary area**, which is factually wrong. - The **pulmonary area** is at the second left intercostal space, making it superior to the tricuspid area (fourth or fifth left intercostal space) [1]. *c>a>b (Mitral > Pulmonary > Tricuspid)* - This order is incorrect as it incorrectly positions the **mitral area** as the most superior point on the left side, which is anatomically inaccurate for auscultation. - The **pulmonary area** is located more superiorly than both the tricuspid and mitral areas in the standard auscultation sequence [1].

Q: What does the given ECG show?

P-pulmonale. ***P-pulmonale*** - The ECG shows tall, peaked **P waves** with an amplitude of more than **2.5 mm in lead II**, which is characteristic of P-pulmonale. - P-pulmonale indicates **right atrial enlargement or hypertrophy**, often due to conditions like severe lung disease (e.g., COPD) or pulmonary hypertension. *Improper calibration* - Improper calibration would typically affect the amplitude of all ECG complexes globally or specific leads consistently, which is not the primary finding here. - The calibration mark (first beat in lead I) appears normal, indicating standard calibration (10mm/mV). *Electrical alternans* - **Electrical alternans** is characterized by beat-to-beat variation in the QRS complex amplitude, which is not visible in this ECG. - It is commonly associated with **pericardial effusion with cardiac tamponade**. *Ventricular bigeminy* - **Ventricular bigeminy** is a pattern where every normal sinus beat is followed by a premature ventricular contraction (PVC). - This ECG shows a regular rhythm with consistent P-QRS-T morphology, without alternating normal and PVC beats.

Q: A 62-year-old patient presents with pain in the calf muscles while walking. The pain subsides with rest. Which of the following is not typically seen in intermittent claudication?

Rest pain at night in advanced stages. ***Rest pain at night in advanced stages*** - Intermittent claudication is defined by pain with exercise that resolves with rest [1]. **Rest pain** indicates critical limb ischemia, a more advanced stage of peripheral artery disease, and is distinct from intermittent claudication itself, although it can develop from it [1]. - While rest pain can occur in patients with severe peripheral artery disease, it is **not typically seen in intermittent claudication**, but rather represents progression to a more severe form of the disease. *Pain gradually increases* - The pain of intermittent claudication typically **gradually increases** during physical activity as the oxygen demand of the muscles exceeds the compromised blood supply. - This progressive pain forces the patient to stop activity, at which point the pain subsides with rest. *Caused most commonly by atherosclerosis* - **Atherosclerosis** is the underlying pathology in the vast majority of cases of peripheral artery disease, leading to stenosis or occlusion of the arteries that supply the lower limbs [1]. - This narrowing of the arterial lumen restricts blood flow, causing inadequate oxygen delivery to muscles during exertion. *Level of occlusion cannot be decided based on symptoms* - The **anatomical level of arterial occlusion** can often be inferred to some extent by the location of the claudication pain (e.g., buttock claudication suggests aortoiliac disease, calf claudication suggests femoropopliteal disease) [1]. - However, the precise extent and severity of the occlusion cannot be solely determined by symptoms, and imaging studies like **duplex ultrasound** or angiography are required for definitive diagnosis.

Q: A 60-year-old male patient with critical mitral stenosis presented with atrial fibrillation. He has a history of multiple episodes of transient ischemic attacks. Which of the following are true regarding preventing stroke in this patient? 1. Only aspirin is given 2. Warfarin is given 3. Direct oral anticoagulants are not indicated 4. Mitral valvotomy should be recommended

2 and 3. ***2 and 3*** - In patients with **mitral stenosis** and **atrial fibrillation**, **warfarin** is the recommended anticoagulant for stroke prevention due to its efficacy in preventing thrombus formation in the left atrium [1]. - **Direct oral anticoagulants (DOACs)** are generally **contraindicated** in patients with moderate to severe mitral stenosis, as their effectiveness and safety in this specific population have not been established. *1 only* - **Aspirin monotherapy** is insufficient for stroke prevention in patients with **atrial fibrillation** and **mitral stenosis**, as their risk of thromboembolism is significantly higher [1]. - Aspirin has a lower efficacy compared to warfarin in preventing cardioembolic strokes originating from left atrial thrombi in this demographic. *1,2,3 and 4* - While warfarin is indicated and DOACs are not, recommending **mitral valvotomy** should be considered in conjunction with anticoagulation, but it is not the sole or primary measure for acute stroke prevention [2]. - The combination of all four statements is incorrect because DOACs are contraindicated, and aspirin alone is inadequate. *2,3 and 4* - Although **warfarin** is indicated and **DOACs** are not, recommending **mitral valvotomy** is a therapeutic intervention for the underlying structural heart disease, not a direct acute stroke prevention medication [2]. - Valvotomy improves hemodynamics and may reduce future thrombus risk, but immediate stroke prevention heavily relies on effective anticoagulation [2].

Q: A 47-year-old man comes to the physician for a follow-up examination. He feels well. He was diagnosed with hypertension 3 months ago. He has smoked one pack of cigarettes daily for 20 years but quit 4 years ago. He occasionally drinks alcohol on the weekends. He walks for 45 minutes daily and eats three meals per day. His current diet consists mostly of canned tuna and cured meats. He started eating whole-wheat bread after he was diagnosed with hypertension. He drinks 1 to 2 cups of coffee daily. His mother has a history of hyperthyroidism. Current medications include hydrochlorothiazide and a multivitamin pill every night before sleeping. His wife told him that he sometimes snores at night, but he reports that he usually sleeps well and feels refreshed in the mornings. His pulse is 80/min, respirations are 18/min, and blood pressure is 148/86 mm Hg. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?

Counsel on dietary modification. ### Counsel on dietary modification - This patient's diet of **canned tuna** and **cured meats** is likely very high in sodium, contributing to his uncontrolled hypertension despite being on hydrochlorothiazide. [2] - Counseling him on a **low-sodium diet** patterned after the **DASH diet** (Dietary Approaches to Stop Hypertension) is the most appropriate next step to improve blood pressure control. [1] ### Conduct a sleep study - While snoring can be a sign of **sleep apnea**, the patient reports sleeping well and feeling refreshed, making sleep apnea less likely to be the primary concern for his hypertension at this point. - Addressing his likely high-sodium diet has a more direct and immediate impact on his uncontrolled blood pressure. [2] ### Add metoprolol - Adding a second antihypertensive medication (like metoprolol) is an option if **lifestyle modifications** and the current diuretic are insufficient. However, addressing preventable dietary factors first is key. - It's important to optimize non-pharmacological interventions before escalating drug therapy, especially when a clear modifiable risk factor like diet is present. [2] ### Start a structured exercise program - The patient already walks for **45 minutes daily**, which meets recommended exercise guidelines (moderate intensity for at least 30 minutes most days of the week). - While an exercise program is generally beneficial, his current exercise regimen is adequate, and dietary sodium is a more prominent and unaddressed factor for his uncontrolled hypertension. [2] ### Measure thyroid-stimulating hormone levels - Although his mother has a history of **hyperthyroidism**, this patient presents with no symptoms suggestive of thyroid dysfunction, such as weight changes, tremors, or significant fatigue. - His controlled pulse and feeling well do not indicate an immediate need for thyroid function testing as a primary cause for his hypertension.

Q: A 45-year-old female with no significant past medical history present to her primary care physician for her annual check up. She missed her several appointments in the past as she says that she does not like coming to the doctor's office. When she last presented 1 year ago, she was found to have an elevated blood pressure reading. She states that she has been in her usual state of health and has no new complaints. Vital signs in the office are as follows: T 98.8 F, BP 153/95 mmHg, HR 80 bpm, RR 14 rpm, SaO2 99% on RA. She appears very anxious during the exam. The remainder of the exam is unremarkable. She reports that her blood pressure was normal when she checked it at the pharmacy 3 months ago. What test would you consider in order to further evaluate this patient?

Ambulatory blood pressure monitoring. ***Ambulatory blood pressure monitoring*** - The patient's **anxiety** in the clinic, history of elevated blood pressure previously, and normal reading at the pharmacy suggest possible **white-coat hypertension**. - **Ambulatory blood pressure monitoring (ABPM)** is the gold standard for diagnosing white-coat hypertension, providing blood pressure readings over a 24-hour period in the patient's natural environment [1]. *Measure TSH and free T4* - While **hyperthyroidism** can cause hypertension, there are no other symptoms (e.g., weight loss, palpitations, heat intolerance) to suggest this as the primary concern. - Measuring thyroid hormones before addressing the immediate question of white-coat hypertension is less appropriate given the patient's presentation. *Measure creatinine level* - An elevated **creatinine level** would indicate potential kidney disease, which can cause secondary hypertension [2]. - However, there are no signs or symptoms pointing towards kidney dysfunction in an otherwise asymptomatic patient with a history of only occasional elevated BP readings [3]. *Repeat vital signs at her next visit* - Simply repeating vital signs at a future clinic visit may not resolve the issue of **white-coat effect**, and the patient's anxiety could persist. - This approach delays a definitive diagnosis and management, which could lead to untreated hypertension if it's not white-coat related [1]. *Obtain an EKG* - An **EKG** assesses for cardiac abnormalities, such as left ventricular hypertrophy, which can be a consequence of long-standing hypertension. - While important in the overall evaluation of hypertension, it does not help differentiate between white-coat hypertension and true sustained hypertension.

Question 1

All of the following are the causes of High output cardiac failure, except?

Accepted Answer

Cor pulmonale

Answer

Systemic AV shunt

Answer

Beri beri

Answer

Anemia

Question 2

Which of the following describes aortic regurgitation murmur?

Accepted Answer

Diastolic murmur

Answer

Ejection systolic murmur

Answer

Ventricular contraction

Answer

Systolic murmur

Question 3

Identify the ECG given below?

Accepted Answer

Torsades de pointes

Answer

Viral myocarditis

Answer

Cardiac tamponade

Answer

Pericarditis

Question 4

What is the correct order for cardiac auscultation on the left side, from superior to inferior?
a. Pulmonary
b. Tricuspid
c. Mitral

Accepted Answer

a>b>c (Pulmonary > Tricuspid > Mitral)

Answer

c>b>a (Mitral > Tricuspid > Pulmonary)

Answer

b>a>c (Tricuspid > Pulmonary > Mitral)

Answer

c>a>b (Mitral > Pulmonary > Tricuspid)

Question 5

What does the given ECG show?

Accepted Answer

P-pulmonale

Answer

Improper calibration

Answer

Electrical alternans

Answer

Ventricular bigeminy

Question 6

A 62-year-old patient presents with pain in the calf muscles while walking. The pain subsides with rest. Which of the following is not typically seen in intermittent claudication?

Accepted Answer

Rest pain at night in advanced stages

Answer

Pain gradually increases

Answer

Caused most commonly by atherosclerosis

Answer

Level of occlusion cannot be decided based on symptoms

Question 7

A 60-year-old male patient with critical mitral stenosis presented with atrial fibrillation. He has a history of multiple episodes of transient ischemic attacks. Which of the following are true regarding preventing stroke in this patient?

1. Only aspirin is given
2. Warfarin is given
3. Direct oral anticoagulants are not indicated
4. Mitral valvotomy should be recommended

Accepted Answer

2 and 3

Answer

1 only

Answer

1,2,3 and 4

Answer

2,3 and 4

Question 8

A 47-year-old man comes to the physician for a follow-up examination. He feels well. He was diagnosed with hypertension 3 months ago. He has smoked one pack of cigarettes daily for 20 years but quit 4 years ago. He occasionally drinks alcohol on the weekends. He walks for 45 minutes daily and eats three meals per day. His current diet consists mostly of canned tuna and cured meats. He started eating whole-wheat bread after he was diagnosed with hypertension. He drinks 1 to 2 cups of coffee daily. His mother has a history of hyperthyroidism. Current medications include hydrochlorothiazide and a multivitamin pill every night before sleeping. His wife told him that he sometimes snores at night, but he reports that he usually sleeps well and feels refreshed in the mornings. His pulse is 80/min, respirations are 18/min, and blood pressure is 148/86 mm Hg. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

Counsel on dietary modification

Answer

Conduct a sleep study

Answer

Add metoprolol

Answer

Start a structured exercise program

Answer

Measure thyroid-stimulating hormone levels

Question 9

A 45-year-old female with no significant past medical history present to her primary care physician for her annual check up. She missed her several appointments in the past as she says that she does not like coming to the doctor's office. When she last presented 1 year ago, she was found to have an elevated blood pressure reading. She states that she has been in her usual state of health and has no new complaints. Vital signs in the office are as follows: T 98.8 F, BP 153/95 mmHg, HR 80 bpm, RR 14 rpm, SaO2 99% on RA. She appears very anxious during the exam. The remainder of the exam is unremarkable. She reports that her blood pressure was normal when she checked it at the pharmacy 3 months ago. What test would you consider in order to further evaluate this patient?

Accepted Answer

Ambulatory blood pressure monitoring

Answer

Measure TSH and free T4

Answer

Measure creatinine level

Answer

Repeat vital signs at her next visit

Answer

Obtain an EKG

Question 10

A 58-year-old man is brought to the emergency department by his family because of severe upper back pain, which he describes as ripping. The pain started suddenly 1 hour ago while he was watching television. He has hypertension for 13 years, but he is not compliant with his medications. He denies the use of nicotine, alcohol or illicit drugs. His temperature is 36.5°C (97.7°F), the heart rate is 110/min and the blood pressure is 182/81 mm Hg in the right arm and 155/71 mm Hg in the left arm. CT scan of the chest shows an intimal flap limited to the descending aorta. Intravenous opioid analgesia is started. Which of the following is the best next step in the management of this patient condition?

Accepted Answer

Intravenous esmolol

Answer

Intravascular ultrasound

Answer

Emergency surgical intervention

Answer

Sublingual nitroglycerin

Answer

Oral metoprolol and/or enalapril

Cardiology — MCQs

Cardiology — MCQs

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