Cardiology Practice Questions

Q: Which of the following is not true regarding Wolff-Parkinson-White (WPW) syndrome?

Prolonged PR interval. ***Prolonged PR interval*** - In WPW syndrome, the presence of an **accessory pathway (Bundle of Kent)** allows for **pre-excitation** of the ventricles, bypassing the AV node's normal delay [1]. - This results in a **shortened PR interval** (typically < 0.12 seconds), not a prolonged one [1]. *Delta wave is seen on ECG* - The **delta wave** is a characteristic finding in WPW, representing the slurred upstroke of the QRS complex due to early ventricular activation via the accessory pathway [1]. - It indicates **ventricular pre-excitation** and is a key diagnostic feature [1], [2]. *Bundle of Kent connects atria to ventricles* - The **Bundle of Kent** is an anomalous muscle fiber bundle that forms an **accessory pathway** directly connecting the atria to the ventricles [1]. - This pathway bypasses the AV node, leading to the characteristic ECG findings and potential re-entrant arrhythmias. *Pre-excitation occurs via accessory pathway* - **Pre-excitation** is the hallmark of WPW syndrome, where electrical impulses bypass the normal conduction system (AV node) and activate ventricular tissue prematurely via an **accessory pathway** [1]. - This leads to the characteristic short PR interval and delta wave on the ECG [2].

Q: Pressure difference of 5 mm Hg between the two upper limbs occurs in which congenital heart disease?

Supra-valvular aortic stenosis. ***Supra-valvular aortic stenosis*** - **Supravalvular aortic stenosis** causes a **pressure gradient** across the aortic valve, leading to a significant **pressure difference** between the upper limbs, typically with a **higher pressure** in the right arm. - This is due to the **Coanda effect**, where the high-velocity jet of blood preferentially flows up the **right subclavian artery** as it exits the aorta. *HOCM (Hypertrophic Obstructive Cardiomyopathy)* - HOCM is characterized by hypertrophy of the **left ventricular septum** causing **outflow tract obstruction**, but it does not typically cause a significant **pressure difference** between the upper limbs. - The obstruction primarily affects **ventricular ejection** rather than differential flow to major arteries. *Coarctation of Aorta* - **Coarctation of the aorta** causes a significant **blood pressure difference** between the upper and lower extremities, with higher pressures in the arms [1]. - However, it does not typically cause a marked **pressure difference between the two upper limbs**, unless the coarctation is pre-ductal and affects the subclavian artery circulation asymmetrically, which is less common for a difference of just 5 mmHg. *TOF (Tetralogy of Fallot)* - **Tetralogy of Fallot** is a cyanotic heart disease involving **pulmonary stenosis**, ventricular septal defect, overriding aorta, and right ventricular hypertrophy [2]. - While it causes significant circulatory abnormalities and potential for **hypoxia**, it does not inherently lead to a measurable **pressure difference** between the upper limbs.

Q: Angle of tracheal bifurcation is increased in which chamber of heart enlargement.

Left atrium. ***Left atrium*** - An enlarged **left atrium** can lift the **left main bronchus**, increasing the angle between the two main bronchi, known as the **carinal angle** (or angle of tracheal bifurcation), visible on a chest X-ray. - This is a common radiological sign seen in conditions causing left atrial enlargement, such as **mitral stenosis** [2]. *Left ventricle* - **Left ventricular enlargement** primarily causes the cardiac apex to shift downward and laterally, but it typically does not directly impinge on the main bronchi to increase the carinal angle [1]. - While it can indirectly affect lung fields due to **pulmonary congestion**, it doesn't cause this specific sign [1]. *Right atrium* - **Right atrial enlargement** causes a bulging of the right border of the heart on a chest X-ray [1]. - It does not directly interact with or displace the main bronchi in a way that would alter the **tracheal bifurcation angle**. *Right ventricle* - **Right ventricular enlargement** can cause the heart to push into the retrosternal space and elevate the apex, but it generally does not impinge upon the main bronchi to change the **carinal angle** [1]. - Its effects are more focused on the anterior and rightward aspects of the heart.

Q: Differential cyanosis is seen in

PDA. ***PDA*** - **Differential cyanosis** occurs in **Patent Ductus Arteriosus (PDA)** with **pulmonary hypertension** and **reversed shunt** [1]. - Deoxygenated blood from the pulmonary artery shunts into the **descending aorta** distal to the subclavian artery, leading to cyanosis in the lower extremities, typically sparing the right upper extremity unless there is a pre-ductal coarctation or an anomalous right subclavian artery from the descending aorta. *All of the options* - This is incorrect because differential cyanosis is a specific finding associated predominantly with **right-to-left shunting** through a patent ductus arteriosus. - While other congenital heart defects can cause cyanosis, few cause the distinct pattern of differential cyanosis. *VSD* - **Ventricular Septal Defect (VSD)** typically causes a **left-to-right shunt**, leading to increased pulmonary blood flow, and eventually pulmonary hypertension [2]. - If Eisenmenger syndrome develops with a **reverses shunt (right-to-left)**, it would cause **generalized cyanosis**, not differential cyanosis, as the shunting occurs at the ventricular level before the great arteries diverge. *ASD* - **Atrial Septal Defect (ASD)** creates a **left-to-right shunt** at the atrial level, increasing pulmonary blood flow [3]. - The development of **Eisenmenger syndrome** with a right-to-left shunt in ASD would also lead to **generalized cyanosis** because deoxygenated blood mixes in the left atrium before being ejected into the systemic circulation.

Q: A patient with VSD in CCF develops clubbing with no cyanosis. The diagnosis is:

Right to left shunt. ***Right to left shunt*** - The development of **clubbing** in a patient with a VSD suggests **chronic hypoxemia**, which in this context indicates a **right-to-left shunt**. [1] - While cyanosis is often present with significant right-to-left shunts, its absence might mean it is **subtle**, or the patient has adjusted to a **lower oxygen saturation threshold** for perceived cyanosis. [2] *Subacute bacterial Endocarditis* - Although **clubbing** can be a feature of **subacute bacterial endocarditis (SBE)**, this condition is more typically associated with systemic symptoms like fever, fatigue, and new or worsening heart murmurs. - The primary presentation here is clubbing in the context of a VSD and CCF, making SBE a less direct explanation for the immediate pathophysiology of clubbing. *Pulm. edema* - **Pulmonary edema** is characterized by **shortness of breath**, coughing, and crackles on pulmonary auscultation, resulting from fluid accumulation in the lungs. [3] - It does not directly cause **clubbing**, which is a sign of chronic tissue hypoxia. *Left to right shunt* - A **left-to-right shunt** in a VSD leads to **pulmonary hypertension** and congestive heart failure but generally does not cause **hypoxemia** or **clubbing**. - Clubbing is a sign of **cyanotic heart disease**, which requires at least a temporary or persistent **right-to-left shunt**.

Q: Inability to perform any work without discomfort is

NYHA 4. ***NYHA 4*** - **Class IV** of the **New York Heart Association (NYHA) Functional Classification** describes individuals who are unable to carry on any physical activity without symptoms, and may even experience symptoms at rest [1]. - This classification indicates **severe heart failure**, where patients experience extreme limitations in their daily life due to discomfort, shortness of breath, or angina [1], [2]. *NYHA 3* - **Class III** patients experience **marked limitation of physical activity**; they are comfortable at rest but ordinary physical activity causes fatigue, palpitations, dyspnea, or anginal pain [1]. - This is a less severe functional impairment than Class IV, as patients are still comfortable at rest, unlike those in Class IV [1]. *NYHA 1* - **Class I** patients have **no limitation of physical activity**; ordinary physical activity does not cause undue fatigue, palpitations, dyspnea, or anginal pain [1]. - This represents the mildest form of heart failure, where there are no symptoms during normal activities [1]. *NYHA 2* - **Class II** patients have **slight limitation of physical activity**; they are comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain [1]. - While there is some limitation, it is not as profound as Class IV, where any activity results in discomfort, and symptoms can occur even at rest [1].

Q: "Square root sign" is a hemodynamic finding seen in

Constrictive pericarditis. ***Constrictive pericarditis*** - The "square root sign" refers to the characteristic **ventricular pressure tracing** seen on cardiac catheterization in constrictive pericarditis, resembling a rapid early diastolic filling followed by a plateau (shaped like the mathematical square root symbol √). - This hemodynamic pattern is due to the **abrupt cessation of ventricular filling** when the stiff, fibrotic pericardium limits further expansion. - This is a **catheterization/hemodynamic finding**, not a radiological imaging finding. *ASD* - An **atrial septal defect** (ASD) is a congenital heart defect involving a hole in the septum separating the atria. - It does not present with a "square root sign" on pressure tracings; rather, it's associated with a **fixed, wide splitting of S2** and right heart enlargement on imaging. *Pleuro-pericardial cyst* - A **pleuro-pericardial cyst** is a benign, fluid-filled sac located near the heart or lungs. - While it may be identified on imaging, it typically causes no hemodynamic changes and thus no "square root sign" on cardiac pressure measurements. *HOCM* - **Hypertrophic obstructive cardiomyopathy** (HOCM) is characterized by thickening of the ventricular walls, leading to dynamic outflow tract obstruction. - Its pressure tracings show a **spike-and-dome pattern** with dynamic LVOT gradient, distinct from the "square root sign."

Q: Epsilon waves are most specific for

Arrhythmogenic RV Cardiomyopathy. ***Arrhythmogenic RV Cardiomyopathy*** - Epsilon waves are small, positive deflections seen at the end of the **QRS complex**, best observed in precordial leads (V1-V3), and are a characteristic ECG finding in **Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)**. - They represent delayed and fragmented electrical activity due to fibrofatty replacement of the right ventricular myocardium in ARVC. *Hypokalemia* - **Hypokalemia** typically manifests on ECG with **U waves**, which are positive deflections following the T wave, not epsilon waves. - Other ECG changes in hypokalemia include flattened T waves and ST-segment depression. *Hypothermia* - **Hypothermia** is associated with the presence of **Osborn waves** (J waves), which are positive deflections at the junction of the QRS complex and the ST segment. - These waves are distinct from epsilon waves and represent slowed repolarization. *PSVT* - **Paroxysmal Supraventricular Tachycardia (PSVT)** is a type of arrhythmia characterized by a narrow QRS complex tachycardia with a regular rhythm. - It does not involve epsilon waves; its ECG features are related to abnormal conduction pathways in the atria or AV node.

Q: Isolated systolic hypertension is defined as:

SBP>140, DBP 140, DBP 140, DBP 150, DBP 160, DBP 140 mmHg.

Question 1

Which of the following is not true regarding Wolff-Parkinson-White (WPW) syndrome?

Accepted Answer

Prolonged PR interval

Answer

Delta wave is seen on ECG

Answer

Bundle of Kent connects atria to ventricles

Answer

Pre-excitation occurs via accessory pathway

Question 2

Pressure difference of 5 mm Hg between the two upper limbs occurs in which congenital heart disease?

Accepted Answer

Supra-valvular aortic stenosis

Answer

HOCM

Answer

Coarctation of Aorta

Answer

TOF

Question 3

Angle of tracheal bifurcation is increased in which chamber of heart enlargement.

Accepted Answer

Left atrium

Answer

Left ventricle

Answer

Right atrium

Answer

Right ventricle

Question 4

Differential cyanosis is seen in

Accepted Answer

PDA

Answer

All of the options

Answer

VSD

Answer

ASD

Question 5

A patient with VSD in CCF develops clubbing with no cyanosis. The diagnosis is:

Accepted Answer

Right to left shunt

Answer

Subacute bacterial Endocarditis

Answer

Pulm. edema

Answer

Left to right shunt

Question 6

A 27-year-old man was assaulted and stabbed on the left side of the chest between the areola and the sternum. He is hemodynamically unstable with jugular venous distention, distant heart sounds, and hypotension. Which of the following findings would be consistent with a diagnosis of hemodynamically significant cardiac tamponade?

Accepted Answer

Equalization of pressures across the 4 chambers on Swan-Ganz monitoring

Answer

Decreased right atrial pressures on Swan-Ganz monitoring

Answer

More than a 10 mm Hg decrease in systolic blood pressure during inspiration (pulsus paradoxus)

Answer

Compression of the left ventricle on echocardiography

Question 7

Inability to perform any work without discomfort is

Accepted Answer

NYHA 4

Answer

NYHA 3

Answer

NYHA 1

Answer

NYHA 2

Question 8

"Square root sign" is a hemodynamic finding seen in

Accepted Answer

Constrictive pericarditis

Answer

ASD

Answer

Pleuro - pericardial cyst

Answer

HOCM

Question 9

Epsilon waves are most specific for

Accepted Answer

Arrhythmogenic RV Cardiomyopathy

Answer

Hypokalemia

Answer

Hypothermia

Answer

PSVT

Question 10

Isolated systolic hypertension is defined as:

Accepted Answer

SBP>140, DBP<90

Answer

SBP>140, DBP<80

Answer

SBP>150, DBP<90

Answer

SBP>160, DBP<90

Cardiology — MCQs

Cardiology — MCQs

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