Cardiology Practice Questions

Q: Which NSAID is most commonly used in Rheumatic fever?

Aspirin. **Explanation:** **Aspirin (Acetylsalicylic acid)** remains the drug of choice for the management of arthritis and carditis without cardiomegaly or heart failure in Acute Rheumatic Fever (ARF). The underlying medical concept is its potent anti-inflammatory action, which provides dramatic relief of joint pain and swelling, typically within 24–48 hours. In ARF, Aspirin is used at anti-inflammatory doses (75–100 mg/kg/day in children) rather than standard analgesic doses. **Analysis of Incorrect Options:** * **Indomethacin:** While a potent NSAID, it is primarily used in pediatrics for the closure of Patent Ductus Arteriosus (PDA) and is not the first-line agent for ARF. * **Phenylbutazone:** This drug is rarely used in modern practice due to its severe side effect profile, including bone marrow suppression (aplastic anemia). * **Rofecoxib:** This is a selective COX-2 inhibitor. These are generally avoided in children and have been associated with increased cardiovascular risks in adults. **High-Yield Clinical Pearls for NEET-PG:** * **Therapeutic Response:** If a patient with suspected Rheumatic arthritis does not respond to Aspirin within 48–72 hours, the diagnosis of ARF should be reconsidered. * **Steroids vs. NSAIDs:** Corticosteroids (Prednisolone) are indicated only when there is **severe carditis** (manifesting as cardiomegaly, CHF, or 3rd-degree heart block). * **Monitoring:** Long-term high-dose Aspirin requires monitoring for **salicylism** (tinnitus, hyperventilation) and awareness of **Reye’s Syndrome** if the child contracts Influenza or Varicella.

Q: A 3-month-old infant is diagnosed with a deletion at the 22q11 chromosome. A routine cardiovascular examination reveals severe congenital cardiac malformation. Which of the following malformations will most likely be associated with 22q11 syndrome?

Tetralogy of Fallot and truncus arteriosus. **Explanation:** The patient presents with **DiGeorge Syndrome (22q11.2 deletion syndrome)**, characterized by the mnemonic **CATCH-22**: **C**ardiac defects, **A**bnormal facies, **T**hymic hypoplasia (T-cell deficiency), **C**left palate, and **H**ypocalcemia (due to parathyroid hypoplasia). **Why Option A is Correct:** The 22q11 deletion results in the maldevelopment of the **3rd and 4th pharyngeal pouches**. This leads to defects in the **neural crest cells**, which are essential for the septation of the **outflow tract (conotruncus)** of the heart. Consequently, "conotruncal" or "cyanotic" heart defects are most common. **Tetralogy of Fallot (TOF)** is the most frequent, followed by **Truncus Arteriosus** and Interrupted Aortic Arch (Type B). **Why Other Options are Incorrect:** * **Option B (TGA):** While a cyanotic defect, TGA is not classically associated with 22q11 syndrome; it is more commonly associated with maternal diabetes. * **Option C (ASD/VSD):** These are common isolated defects or associated with Down Syndrome (Trisomy 21), particularly endocardial cushion defects (AVSD). * **Option D (Coarctation of the aorta):** This is the hallmark cardiac association for **Turner Syndrome (45, XO)**. **High-Yield Clinical Pearls for NEET-PG:** * **Most common defect in DiGeorge:** Tetralogy of Fallot. * **Most specific defect for DiGeorge:** Interrupted Aortic Arch (Type B) or Truncus Arteriosus. * **Immunology Link:** Patients have recurrent viral/fungal infections due to T-cell deficiency (absent thymic shadow on X-ray). * **Metabolic Link:** Seizures in the neonatal period may occur due to hypocalcemia (hypoparathyroidism).

Q: A 2-month-old baby with central cyanosis presented with specific findings on chest X-ray and ECG. What is the most probable underlying diagnosis?

Ebstein anomaly. ***Ebstein anomaly*** - Presents with **central cyanosis** in infants due to **tricuspid valve displacement** causing right-to-left shunting through atrial septal defect. - Classic chest X-ray shows **massive cardiomegaly** with **box-shaped heart** and ECG reveals **tall P waves**, **RBBB**, and **Wolff-Parkinson-White pattern**. *Tetralogy of Fallot* - While it causes **central cyanosis**, chest X-ray typically shows **boot-shaped heart** with decreased pulmonary vascularity, not massive cardiomegaly. - ECG shows **right ventricular hypertrophy** without the characteristic **WPW pattern** seen in Ebstein anomaly. *Hypoplastic left heart syndrome* - Causes **severe cyanosis** and heart failure in neonates, but chest X-ray shows **pulmonary edema** and **left atrial enlargement**. - ECG demonstrates **right axis deviation** and **right ventricular hypertrophy** without the massive cardiomegaly pattern. *Coarctation of the aorta* - Typically presents with **differential cyanosis** (lower body) rather than central cyanosis in infants. - Chest X-ray may show **rib notching** in older children and **left ventricular enlargement**, not the box-shaped massive cardiomegaly.

Q: What is the most common heart abnormality in children?

Ventricular septal defect. **Explanation:** **Ventricular Septal Defect (VSD)** is the most common congenital heart disease (CHD) in children, accounting for approximately **25–30%** of all cardiac malformations. It involves a hole in the interventricular septum, leading to a left-to-right shunt. While many small VSDs (especially muscular types) close spontaneously in early childhood, they remain the most frequently diagnosed abnormality at birth. **Analysis of Options:** * **Atrial Septal Defect (ASD):** While common, it is less frequent than VSD in children. However, it is the most common CHD diagnosed in **adults** because it often remains asymptomatic until later in life. * **Tetralogy of Fallot (TOF):** This is the most common **cyanotic** heart disease after infancy (beyond one year of age). Transposition of the Great Arteries (TGA) is the most common cyanotic CHD at birth. * **Total Anomalous Pulmonary Venous Connection (TAPVC):** This is a rare cyanotic heart disease characterized by pulmonary veins draining into the right atrium instead of the left. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type of VSD:** Membranous (Perimembranous) VSD. * **Most common CHD overall:** VSD. * **Most common CHD in Down Syndrome:** Atrioventricular Septal Defect (AVSD/Endocardial cushion defect). * **Most common CHD in Turner Syndrome:** Bicuspid Aortic Valve (followed by Coarctation of Aorta). * **Most common CHD in Congenital Rubella:** Patent Ductus Arteriosus (PDA). * **Auscultation:** VSD typically presents with a harsh **pansystolic murmur** best heard at the left lower sternal border.

Q: According to the American Heart Association & World Heart Federation 2015 criteria, low risk for acute rheumatic fever is defined as an incidence of less than which of the following per 100,000 school-aged children per year?

2. ### Explanation The classification of populations into "low risk" or "moderate-to-high risk" for Acute Rheumatic Fever (ARF) is crucial because the diagnostic criteria (Jones Criteria) differ based on this risk profile. **1. Why Option B is Correct:** According to the **2015 Revised Jones Criteria** (endorsed by the American Heart Association and the World Heart Federation), a population is defined as **low risk** if: * The incidence of ARF is **< 2 per 100,000 school-aged children (ages 5–14 years)** per year, **OR** * The prevalence of Rheumatic Heart Disease (RHD) is **≤ 1 per 1,000 population** per year (at any age). In low-risk populations, the diagnostic criteria are stricter to avoid overdiagnosis. In moderate-to-high risk populations (incidence ≥ 2 per 100,000), the criteria are expanded (e.g., monoarthritis and polyarthralgia are accepted as major and minor criteria, respectively). **2. Why Other Options are Incorrect:** * **Option A (1):** While 1 per 1,000 is the threshold for RHD prevalence, it is not the threshold for ARF incidence. * **Options C & D (0.1 and 0.01):** These values are far too low. While developed nations have seen a massive decline in ARF, the standardized epidemiological cutoff remains at 2 per 100,000. **3. High-Yield NEET-PG Pearls:** * **Jones Criteria 2015 Update:** The most significant change was the stratification of criteria based on risk (Low vs. Moderate/High). * **Major Criteria for Low Risk:** Carditis (clinical or subclinical), Polyarthritis, Chorea, Erythema marginatum, and Subcutaneous nodules. * **Major Criteria for Moderate/High Risk:** Includes the above, but also accepts **Monoarthritis** or **Polyarthralgia**. * **Subclinical Carditis:** Echocardiographic evidence of valvulitis is now considered a "Major" criterion even if a murmur is absent (in all risk groups). * **India's Status:** India is considered a **Moderate-to-High risk** zone for ARF/RHD.

Q: Which of the following is NOT a component of Kawasaki disease?

Purulent conjunctivitis. **Explanation:** Kawasaki Disease (KD) is an acute, self-limiting systemic medium-vessel vasculitis. The diagnosis is clinical, based on the presence of high-grade fever for at least 5 days plus 4 out of 5 principal criteria. **Why "Purulent Conjunctivitis" is the correct answer:** The ocular hallmark of Kawasaki disease is **bilateral, non-exudative (bulbar) conjunctival injection**. It is typically painless and, crucially, **spares the limbus** (the area around the iris). The presence of pus or discharge (purulent conjunctivitis) points away from KD and suggests a viral or bacterial etiology. **Analysis of Incorrect Options:** * **Pedal Edema:** This is a classic feature of the "Extremity Changes" criterion. In the acute phase, patients present with erythema and painful edema of the hands and feet. (In the subacute phase, periungual desquamation occurs). * **Truncal Rash:** A polymorphous exanthema (usually maculopapular or morbilliform) that primarily involves the trunk and extremities is a core diagnostic criterion. * **Pharyngeal Congestion:** This falls under "Oropharyngeal Changes," which include erythema of the pharynx, "strawberry tongue," and cracked, erythematous lips. **High-Yield Clinical Pearls for NEET-PG:** * **Most Serious Complication:** Coronary artery aneurysms (occurs in 20-25% of untreated cases). * **Treatment:** High-dose IVIG (2g/kg) and Aspirin (to prevent coronary thrombosis). * **Incomplete Kawasaki:** Diagnosed when fever is present with <4 criteria but supportive lab findings (e.g., high ESR/CRP, sterile pyuria, or thrombocytosis) or echocardiographic abnormalities are found. * **Age Group:** Primarily affects children <5 years old.

Q: A 12-year-old child with a history of rheumatic heart disease presents with a one-month history of low-grade fever. She has pallor, splenomegaly, clubbing, and microscopic hematuria. What is the most important diagnostic test to perform?

Blood culture. **Explanation:** The clinical presentation of a child with pre-existing **Rheumatic Heart Disease (RHD)** presenting with prolonged low-grade fever, splenomegaly, clubbing, and microscopic hematuria is a classic textbook description of **Infective Endocarditis (IE)**. In any patient with structural heart disease and unexplained fever, IE must be ruled out first. **Why Blood Culture is the correct answer:** Blood culture is the **"Gold Standard"** and a **Major Criterion** according to the **Modified Duke Criteria** for diagnosing IE. It identifies the causative organism and determines antibiotic sensitivity, which is critical for life-saving treatment. Microscopic hematuria in this patient (focal glomerulonephritis) and clubbing are peripheral "immunological phenomena" strongly suggestive of IE. **Why other options are incorrect:** * **ASO Titer:** This is used to diagnose a recent Group A Streptococcal infection (Acute Rheumatic Fever). While the patient has a history of RHD, the current subacute presentation points toward endocarditis, not a fresh episode of rheumatic fever. * **C-reactive Protein (CRP):** This is a non-specific marker of inflammation. While it will likely be elevated, it does not provide a definitive diagnosis or guide specific therapy. * **Urine Culture:** While the patient has hematuria, this is typically due to immune-complex mediated glomerulonephritis or embolic phenomena from the heart valves, not a primary urinary tract infection. **High-Yield Clinical Pearls for NEET-PG:** * **Modified Duke Criteria:** Diagnosis requires 2 Major, or 1 Major + 3 Minor, or 5 Minor criteria. * **Most common organism in IE (Overall):** *Staphylococcus aureus*. * **Most common organism in Subacute IE (Native valve):** *Viridans group Streptococci*. * **Echocardiography:** The other Major Criterion is the presence of vegetation, abscess, or new valvular regurgitation on Echo (TEE is more sensitive than TTE).

Q: A 2-week-old neonate presents with central cyanosis, a grade II murmur, a single S2, and plethoric lungs. What is the most likely diagnosis?

Transposition of the great arteries (TGA). ### Explanation The correct diagnosis is **Transposition of the Great Arteries (TGA)**. **1. Why TGA is the correct answer:** TGA is the most common cause of cyanotic congenital heart disease (CCHD) presenting in the first two weeks of life. * **Cyanosis:** Due to parallel circulation where deoxygenated blood returns to the body. * **Single S2:** Because the aorta is anterior and the pulmonary artery is posterior, the closure of the aortic valve (A2) masks the pulmonary valve (P2). * **Plethoric Lungs:** Unlike many other cyanotic conditions, TGA (without pulmonary stenosis) features **increased pulmonary blood flow**, leading to pulmonary plethora on X-ray. * **Murmur:** Often absent or soft (Grade II) unless there is an associated VSD. **2. Why other options are incorrect:** * **TAPVC:** While it presents with plethoric lungs and cyanosis, it typically features a "Snowman" or "Figure-of-8" appearance on X-ray (in the supracardiac type) and usually presents slightly later or with more severe respiratory distress if obstructed. * **Tetralogy of Fallot (TOF):** Characterized by **oligemic lungs** (decreased blood flow) and a loud ejection systolic murmur due to right ventricular outflow tract obstruction. It rarely presents with severe cyanosis in the first two weeks. * **Pulmonary Atresia:** Presents with severe cyanosis and **oligemic lungs** due to the lack of blood flow to the pulmonary circuit. **3. High-Yield Clinical Pearls for NEET-PG:** * **X-ray finding in TGA:** "Egg-on-a-string" appearance (narrow mediastinum due to stress-induced thymic atrophy and malposed vessels). * **Management:** Immediate administration of **Prostaglandin E1 (Alprostadil)** to keep the ductus arteriosus open; definitive treatment is the **Arterial Switch Operation (Jatene procedure)**. * **Hyperoxic Test:** Used to differentiate cardiac cyanosis (minimal rise in $PaO_2$) from respiratory causes.

Question 1

Which NSAID is most commonly used in Rheumatic fever?

Accepted Answer

Aspirin

Answer

Indomethacin

Answer

Phenylbutazone

Answer

Rofecoxib

Question 2

A 4-year-old child presents with high fever, a toxic appearance, eruptions on the trunk and proximal extremities, bilateral bulbar conjunctivitis without discharge, fissured-crusted red lips, and limb edema making walking difficult. She also has desquamation in the perineum and fingertips, along with cervical adenopathy. What is the most likely diagnosis?

Accepted Answer

Kawasaki syndrome

Answer

Polyarteritis nodosa (PAN)

Answer

Henoch-Schönlein purpura (HSP)

Answer

Erythema infectiosum

Question 3

A 3-month-old infant is diagnosed with a deletion at the 22q11 chromosome. A routine cardiovascular examination reveals severe congenital cardiac malformation. Which of the following malformations will most likely be associated with 22q11 syndrome?

Accepted Answer

Tetralogy of Fallot and truncus arteriosus

Answer

Transposition of the great arteries

Answer

Atrial septal and ventricular septal defects

Answer

Coarctation of the aorta

Question 4

A 2-month-old baby with central cyanosis presented with specific findings on chest X-ray and ECG. What is the most probable underlying diagnosis?

Accepted Answer

Ebstein anomaly

Answer

Tetralogy of Fallot

Answer

Hypoplastic left heart syndrome

Answer

Coarctation of the aorta

Question 5

What is the most common heart abnormality in children?

Accepted Answer

Ventricular septal defect

Answer

Atrial septal defect

Answer

Tetralogy of Fallot

Answer

Total anomalous pulmonary venous connection

Question 6

According to the American Heart Association & World Heart Federation 2015 criteria, low risk for acute rheumatic fever is defined as an incidence of less than which of the following per 100,000 school-aged children per year?

Accepted Answer

2

Answer

1

Answer

0.1

Answer

0.01

Question 7

Which of the following is NOT a component of Kawasaki disease?

Accepted Answer

Purulent conjunctivitis

Answer

Pedal edema

Answer

Truncal rash

Answer

Pharyngeal congestion

Question 8

A 12-year-old child with a history of rheumatic heart disease presents with a one-month history of low-grade fever. She has pallor, splenomegaly, clubbing, and microscopic hematuria. What is the most important diagnostic test to perform?

Accepted Answer

Blood culture

Answer

Antistreptolysin O titer

Answer

C-reactive protein

Answer

Urine culture

Question 9

A 2-week-old neonate presents with central cyanosis, a grade II murmur, a single S2, and plethoric lungs. What is the most likely diagnosis?

Accepted Answer

Transposition of the great arteries (TGA)

Answer

Total anomalous pulmonary venous connection (TAPVC)

Answer

Tetralogy of Fallot (TOF)

Answer

Pulmonary atresia

Question 10

Which of the following statements regarding patent ductus arteriosus (PDA) is incorrect?

Accepted Answer

Bacterial endocarditis is more frequent with small PDAs.

Answer

Spontaneous closure occurs in some term infants.

Answer

Pulmonary hypertension can develop.

Answer

Recurrent chest infections and congestive failure may develop.

Cardiology — MCQs

Cardiology — MCQs

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