Cardiology Practice Questions

Q: Which one of the following is not included as a major criterion in the Jones criteria?

Elevated ESR. The **Jones Criteria** (revised by the AHA) are used to diagnose the first episode of **Acute Rheumatic Fever (ARF)**, which occurs as a non-suppurative sequela of Group A Streptococcal pharyngitis. ### Why Elevated ESR is the Correct Answer **Elevated ESR** (Erythrocyte Sedimentation Rate) is a **Minor Criterion**, not a major one. Minor criteria represent non-specific systemic signs of inflammation or laboratory findings. These include: * **Clinical:** Arthralgia, Fever ($\geq 38.5^\circ C$). * **Laboratory:** Elevated Acute Phase Reactants (ESR $\geq 60$ mm/hr or CRP $\geq 3.0$ mg/dL). * **ECG:** Prolonged PR interval (unless carditis is a major criterion). ### Why the Other Options are Incorrect Options A, B, and C are all **Major Criteria**, which are more specific clinical manifestations of ARF. The mnemonic **J♥NES** is commonly used: * **J - Joint Involvement (Arthritis):** Specifically migratory polyarthritis (Option B). * **♥ - Carditis:** Can manifest as pancarditis (Option A), involving the endocardium, myocardium, and pericardium. * **N - Nodules:** Subcutaneous nodules (Option C), which are firm and painless. * **E - Erythema Marginatum:** A characteristic pink, evanescent, non-pruritic rash. * **S - Sydenham Chorea:** Purposeless, involuntary movements (St. Vitus' Dance). ### NEET-PG High-Yield Pearls * **Diagnosis Requirement:** 2 Major OR 1 Major + 2 Minor criteria, PLUS evidence of preceding GAS infection (Positive throat culture, Rapid Antigen test, or Elevated/Rising ASO titer). * **Exception:** Sydenham chorea or indolent carditis can diagnose ARF without evidence of preceding infection. * **Most Common Manifestation:** Arthritis (75%). * **Most Serious Manifestation:** Carditis (can lead to chronic Rheumatic Heart Disease, most commonly affecting the **Mitral Valve**).

Q: A two-month-old infant presents with marked respiratory distress, cyanosis, and bilateral crepitations. The infant's heart rate is 180/min, respiratory rate is 56/min, and the liver span is 7.5 cm. The child has had repeated episodes of fever, cough, and respiratory distress since birth. Cardiovascular examination reveals a grade III ejection systolic murmur in the left parasternal area. Chest X-ray shows cardiomegaly with a narrow base and plethoric lung fields. What is the most likely diagnosis?

Transposition of great arteries. **Explanation:** The clinical presentation points toward a **cyanotic congenital heart disease (CCHD)** with **increased pulmonary blood flow**. **1. Why Transposition of the Great Arteries (TGA) is correct:** * **Clinical Triad:** The infant presents with early-onset cyanosis, congestive heart failure (CHF) symptoms (respiratory distress, crepitations, hepatomegaly), and recurrent respiratory infections. * **Radiology:** The "narrow base" (due to the anteroposterior alignment of the great vessels) and "cardiomegaly" create the classic **"Egg-on-a-string" appearance**, which is pathognomonic for TGA. * **Hemodynamics:** Unlike Tetralogy of Fallot, TGA presents with **plethoric lung fields** (increased pulmonary vascularity) because the pulmonary and systemic circulations are in parallel. The ejection systolic murmur is often due to associated defects like VSD or ASD, which are necessary for survival. **2. Why the other options are incorrect:** * **Tetralogy of Fallot (TOF):** While it causes cyanosis, it typically presents with **decreased** pulmonary blood flow (oligemic lung fields) and a "boot-shaped heart." CHF is rare in TOF. * **Congenital Methemoglobinemia:** Presents with "chocolate-colored" cyanosis that does not improve with oxygen, but it does not cause cardiomegaly, murmurs, or plethoric lung fields. * **Cystic Fibrosis:** Primarily a pulmonary/gastrointestinal disease. While it causes respiratory distress and cough, it would not explain a grade III murmur or the specific "narrow base" cardiac silhouette. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cyanotic heart disease at birth:** TGA. * **Most common cyanotic heart disease after 1 year of age:** TOF. * **X-ray Sign:** Egg-on-a-string (TGA). * **Management:** Prostaglandin E1 (to keep the ductus open) followed by the **Arterial Switch Operation (Jatene procedure)**, ideally performed in the first 2 weeks of life.

Q: Which of the following statements is true regarding the major criteria for Jones in acute rheumatic fever?

Sydenham chorea is a late manifestation.. ### Explanation The **Jones Criteria** (revised by AHA) are the cornerstone for diagnosing Acute Rheumatic Fever (ARF). Understanding the temporal sequence and characteristics of these major manifestations is crucial for NEET-PG. **1. Why Option B is Correct:** **Sydenham Chorea** (St. Vitus' Dance) is characterized by involuntary, purposeless movements and emotional lability. It has a long latent period (1–6 months) after the initial Group A Streptococcal infection. Consequently, it is a **late manifestation** and often appears when other signs like arthritis or elevated ESR/CRP have subsided. **2. Why Other Options are Incorrect:** * **Option A:** **Migratory Polyarthritis** is the **earliest** and most common clinical manifestation (seen in ~75% of cases). Carditis usually appears within the first 3 weeks but is not the earliest. * **Option C:** ARF characteristically involves **large joints** (knees, ankles, elbows, wrists) in a migratory pattern. Small joint involvement is rare and more suggestive of conditions like Rheumatoid Arthritis. * **Option D:** **Subcutaneous nodules** are firm, painless, and typically located over **bony prominences or extensor surfaces** (e.g., olecranon, patella), not flexor aspects. They are strongly associated with severe carditis. **Clinical Pearls for NEET-PG:** * **JONES Criteria Mnemonic:** **J**oints (Polyarthritis), **O** (Carditis - shaped like a heart), **N**odules, **E**rythema marginatum, **S**ydenham chorea. * **Echo-Carditis:** Subclinical carditis (detected only by Echo) is now considered a **Major Criterion** in all populations. * **Arthralgia vs. Arthritis:** In high-risk populations, monoarthritis or polyarthralgia can be considered major criteria. * **Chorea Exception:** If chorea is present, you do not need evidence of a preceding Strep infection to diagnose ARF.

Q: A newborn was diagnosed with a congenital abnormality resulting in transposition of great vessels. While preparing the infant for surgery, the medical team needed to keep the ductus arteriosus open. They achieved this by infusing:

Alprostadil. **Explanation:** In **Transposition of the Great Arteries (TGA)**, the pulmonary and systemic circulations function in parallel rather than in series. This condition is incompatible with life unless there is a communication (shunting) between the two circuits to allow mixing of oxygenated and deoxygenated blood. The **Ductus Arteriosus** provides this vital shunt in the neonatal period. **Why Alprostadil is correct:** **Alprostadil (Prostaglandin E1/PGE1)** is a potent vasodilator. In utero, endogenous prostaglandins keep the ductus arteriosus patent. After birth, oxygen levels rise and prostaglandin levels fall, leading to ductal closure. Administering exogenous Alprostadil maintains the patency of the ductus (**"PDA maintenance"**), ensuring adequate systemic oxygenation until definitive surgical correction (e.g., Arterial Switch Operation) can be performed. **Why the other options are incorrect:** * **Indomethacin:** This is a NSAID that inhibits prostaglandin synthesis. It is used to **close** a patent ductus arteriosus (PDA) in premature infants, which would be fatal in this clinical scenario. * **Cortisol:** While glucocorticoids are used in neonatology for lung maturity (antenatal) or refractory hypotension, they have no role in maintaining ductal patency. * **Tacrolimus:** An immunosuppressant (calcineurin inhibitor) used to prevent organ transplant rejection; it has no effect on the ductus arteriosus. **NEET-PG High-Yield Pearls:** * **Ductus-dependent lesions:** Include TGA, Tricuspid Atresia, Coarctation of the Aorta, and Hypoplastic Left Heart Syndrome. All require PGE1. * **Side effect of Alprostadil:** **Apnea** is a common side effect; clinicians must be prepared for intubation. * **Closure of PDA:** Pharmacological closure is achieved via **Indomethacin or Ibuprofen** (IV). * **Anatomical Remnant:** The closed ductus arteriosus becomes the **Ligamentum Arteriosum**.

Q: Congenital long QT syndrome is associated with neonatal:

Sinus bradycardia. **Explanation:** **1. Why Sinus Bradycardia is Correct:** Congenital Long QT Syndrome (LQTS) is a channelopathy characterized by delayed repolarization of the myocardium. In neonates, this delay in the electrical cycle often manifests as **fetal or neonatal sinus bradycardia**. The underlying mechanism involves a prolonged refractory period of the ventricular myocardium, which can exert an inhibitory effect on the sinoatrial (SA) node or result in a functional 2:1 atrioventricular (AV) block. Bradycardia is often the earliest clinical sign of LQTS and can be detected in utero during routine fetal monitoring. **2. Why Other Options are Incorrect:** * **Sinus Tachycardia:** This is physiologically opposite to the presentation of LQTS. LQTS patients typically have a lower-than-normal heart rate for their age. * **Supraventricular Tachycardia (SVT):** While SVT is a common neonatal arrhythmia, it is not specifically associated with the pathophysiology of LQTS. * **Ventricular Tachycardia (VT):** While LQTS can lead to a specific type of polymorphic VT known as *Torsades de Pointes*, the question asks for the most characteristic neonatal association. Sinus bradycardia is a more consistent finding in the neonatal period and often precedes the development of life-threatening ventricular arrhythmias. **3. High-Yield Clinical Pearls for NEET-PG:** * **Jervell and Lange-Nielsen Syndrome:** Autosomal recessive LQTS associated with **sensorineural deafness**. * **Romano-Ward Syndrome:** Autosomal dominant LQTS (more common, no deafness). * **Torsades de Pointes:** The classic "twisting of points" polymorphic VT seen in LQTS; treated with **Magnesium Sulfate**. * **Neonatal Screening:** Any neonate with persistent unexplained bradycardia should receive an ECG to measure the QTc interval (Normal 470ms is suspicious).

Q: Which of the following statements is false about erythema marginatum?

Clears from the center and leaves a rash behind. **Explanation:** **Erythema Marginatum** is a hallmark cutaneous manifestation of **Acute Rheumatic Fever (ARF)** and serves as one of the Major Criteria in the **Jones Criteria** [1]. 1. **Why Option B is the correct (False) statement:** Erythema marginatum is characterized by its **evanescent (fleeting)** nature. It begins as pinkish-red macules or papules that spread peripherally. As the lesion expands, it **clears centrally**, leaving a sharp, wavy, or "serpiginous" erythematous border. Crucially, it **does not leave a permanent rash or scar behind**; the skin returns to its normal appearance once the lesion fades. 2. **Analysis of Incorrect Options:** * **Option A:** True. The rash typically starts as small, non-pruritic pink papules that extend outward. * **Option C:** True. It is the pathognomonic skin manifestation of ARF, though it occurs in less than 5% of patients. * **Option D:** True. In the context of ARF, erythema marginatum is almost exclusively seen in patients who also have **carditis** [1]. It is rarely, if ever, seen as an isolated finding. **Clinical Pearls for NEET-PG:** * **Morphology:** Non-pruritic, non-tender, blanching, and serpiginous (snake-like) borders. * **Location:** Primarily affects the **trunk and proximal extremities**; it characteristically **spares the face**. * **Triggers:** The rash is transient and can be accentuated by the application of heat (e.g., a hot shower). * **Association:** Highly specific for ARF and strongly associated with a higher risk of underlying rheumatic heart disease [1].

Q: What maternal condition should be evaluated in a fetus diagnosed with congenital heart block?

Systemic lupus erythematosus. **Explanation:** The diagnosis of **congenital heart block (CHB)** in a fetus or neonate is strongly associated with maternal autoimmune diseases, most notably **Systemic Lupus Erythematosus (SLE)** and Sjögren’s syndrome. The underlying mechanism involves the transplacental passage of maternal **anti-Ro (SS-A)** and **anti-La (SS-B)** antibodies. These IgG antibodies cross the placenta (typically between 18–24 weeks of gestation) and cause an inflammatory reaction (myocarditis) followed by progressive fibrosis and calcification of the fetal AV node. This damage is permanent and results in a complete (third-degree) heart block. Notably, many mothers are asymptomatic at the time of fetal diagnosis and are only diagnosed with SLE or Sjögren’s after the heart block is detected. **Analysis of Incorrect Options:** * **A. Antiphospholipid syndrome:** While often co-existing with SLE, it is primarily associated with recurrent miscarriages and thrombotic events rather than fetal conduction defects. * **B. Congenital heart defects:** While structural defects (like Left Atrial Isomerism) can cause heart block, the question asks for a *maternal condition* to be evaluated. * **D. Hemolytic anemia:** This is not a known cause of fetal conduction system destruction. **High-Yield Pearls for NEET-PG:** * **Antibodies:** Anti-Ro (SS-A) is the most specific marker for Neonatal Lupus/CHB. * **Neonatal Lupus:** Besides CHB, it presents with a characteristic "raccoon-eye" or periorbital rash and cytopenias. * **Reversibility:** The skin and hematological manifestations are transient (disappear as maternal antibodies wane), but the **heart block is permanent** and often requires a pacemaker. * **Treatment:** Maternal fluorinated corticosteroids (e.g., Dexamethasone) may be used to reduce fetal inflammation, but they cannot reverse a complete block.

Q: What is the most common presentation of a double aortic arch in infants?

Tracheal compression symptoms. **Explanation:** **Double Aortic Arch (DAA)** is the most common type of symptomatic vascular ring. It occurs when both the right and left embryonic fourth aortic arches persist, forming a complete ring around the trachea and esophagus. **1. Why Tracheal Compression is Correct:** In infants, the trachea is highly compliant and easily compressible. Because the ring tightly encircles the airway, the most frequent and earliest clinical manifestations are respiratory. These include **expiratory stridor** (often called "noisy breathing"), barking cough, and respiratory distress. While the esophagus is also compressed, respiratory symptoms typically predominate and present earlier than feeding difficulties. **2. Analysis of Incorrect Options:** * **A. Dysphagia:** While esophageal compression occurs (dysphagia lusoria), it is usually less prominent than respiratory distress in infancy. It may become more apparent when the child starts solid foods. * **C. Positional hyperemia/Edema:** These are features of venous obstruction (like Superior Vena Cava Syndrome) or thoracic outlet syndrome, not a vascular ring. * **D. Bleeding:** This is not a feature of DAA. Hemoptysis or hematemesis would only occur in rare, late-stage complications like an aorto-esophageal fistula. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** CT or MRI angiography (to visualize the vascular anatomy). * **Initial Screening:** Barium swallow (shows bilateral/posterior indentation of the esophagus). * **Physical Exam:** Stridor often improves with **neck hyperextension** (which pulls the ring away from the trachea). * **Anatomy:** The **right arch** is usually larger and higher than the left arch in a DAA.

Q: Which of the following statements is NOT true about Tetralogy of Fallot (TOF)?

Atrial septal defect is one of the components of TOF.. **Explanation:** Tetralogy of Fallot (TOF) is defined by a specific constellation of four anatomical defects. Understanding these components is crucial for identifying the incorrect statement. **1. Why Option C is the correct answer (The "NOT true" statement):** The four classic components of TOF are: 1. **Ventricular Septal Defect (VSD):** Large and malaligned. 2. **Overriding of the Aorta:** The aorta sits over the VSD. 3. **Right Ventricular Outflow Tract Obstruction (RVOTO):** Most commonly infundibular pulmonary stenosis. 4. **Right Ventricular Hypertrophy (RVH):** Occurs secondary to the high pressure required to pump against the obstruction. An **Atrial Septal Defect (ASD)** is not a component of the "Tetralogy." When an ASD is present along with TOF, the condition is known as **Pentalogy of Fallot.** **2. Analysis of incorrect options:** * **Option A:** TOF is indeed the most common cyanotic heart disease (CHD) beyond infancy. (Note: Transposition of the Great Arteries is the most common cyanotic CHD at birth). * **Option B:** The degree of cyanosis and clinical severity are directly proportional to the severity of pulmonary stenosis. More obstruction leads to more right-to-left shunting across the VSD. * **Option D:** The "boot-shaped heart" (**Coeur en sabot**) is a classic radiological finding caused by an upturned apex (due to RVH) and a concave pulmonary segment. **Clinical Pearls for NEET-PG:** * **Murmur:** The murmur in TOF is due to **pulmonary stenosis** (ejection systolic), NOT the VSD (which is usually large and non-restrictive). * **X-ray:** Characterized by "Oligaemic lung fields" due to reduced pulmonary blood flow. * **Management:** Squatting helps during a "Tet spell" by increasing systemic vascular resistance, which reduces the right-to-left shunt. * **Drug of Choice for Tet Spell:** Morphine or Beta-blockers (Propranolol).

Q: Which of the following can cause recurrent pulmonary infections, except?

Tetralogy of Fallot (TOF). **Explanation:** The core concept behind recurrent pulmonary infections in congenital heart disease (CHD) is **increased pulmonary blood flow (Left-to-Right Shunt)**. When excess blood reaches the lungs, it leads to pulmonary congestion, interstitial edema, and decreased lung compliance. This fluid-rich environment impairs local immune mechanisms and provides a nidus for bacterial growth, leading to frequent pneumonia. * **Why Tetralogy of Fallot (TOF) is the correct answer:** TOF is a **cyanotic** heart disease characterized by **decreased pulmonary blood flow** due to right ventricular outflow tract obstruction (pulmonary stenosis). Because the lungs are "protected" from high pressure and volume, these patients do not typically suffer from recurrent pulmonary infections. Instead, they present with cyanosis and "Tet spells." * **Why the other options are incorrect:** * **VSD & ASD:** These are **Acyanotic** CHDs with **Left-to-Right shunts**. They cause pulmonary plethora (increased blood flow), making the patient highly susceptible to recurrent lower respiratory tract infections (LRTIs). VSD usually presents earlier and more severely than ASD. * **Recurrent LRTIs:** This option is a clinical manifestation of the underlying shunt physiology mentioned above. **Clinical Pearls for NEET-PG:** 1. **Acyanotic CHD (VSD, ASD, PDA):** Increased pulmonary blood flow → Recurrent LRTIs + Congestive Heart Failure. 2. **Cyanotic CHD (TOF, Tricuspid Atresia):** Decreased pulmonary blood flow → Cyanosis + Hypoxic spells (No recurrent LRTIs). 3. **Exception:** Transposition of the Great Arteries (TGA) is a cyanotic CHD that *can* have increased pulmonary flow and thus may present with infections. 4. **VSD** is the most common congenital heart disease overall.

Question 1

Which one of the following is not included as a major criterion in the Jones criteria?

Accepted Answer

Elevated ESR

Answer

Pancarditis

Answer

Arthritis

Answer

Subcutaneous nodules

Question 2

A two-month-old infant presents with marked respiratory distress, cyanosis, and bilateral crepitations. The infant's heart rate is 180/min, respiratory rate is 56/min, and the liver span is 7.5 cm. The child has had repeated episodes of fever, cough, and respiratory distress since birth. Cardiovascular examination reveals a grade III ejection systolic murmur in the left parasternal area. Chest X-ray shows cardiomegaly with a narrow base and plethoric lung fields. What is the most likely diagnosis?

Accepted Answer

Transposition of great arteries

Answer

Congenital methemoglobinemia

Answer

Cystic fibrosis

Answer

Tetralogy of Fallot

Question 3

Which of the following statements is true regarding the major criteria for Jones in acute rheumatic fever?

Accepted Answer

Sydenham chorea is a late manifestation.

Answer

Carditis is the earliest clinical manifestation seen in acute rheumatic fever.

Answer

Involvement of small joints is a characteristic feature.

Answer

Subcutaneous nodules are seen on flexor aspects of the limbs.

Question 4

A newborn was diagnosed with a congenital abnormality resulting in transposition of great vessels. While preparing the infant for surgery, the medical team needed to keep the ductus arteriosus open. They achieved this by infusing:

Accepted Answer

Alprostadil

Answer

Cortisol

Answer

Indomethacin

Answer

Tacrolimus

Question 5

Congenital long QT syndrome is associated with neonatal:

Accepted Answer

Sinus bradycardia

Answer

Sinus tachycardia

Answer

Supraventricular tachycardia

Answer

Ventricular tachycardia

Question 6

Which of the following statements is false about erythema marginatum?

Accepted Answer

Clears from the center and leaves a rash behind

Answer

Begins as a pink papule

Answer

Is the classical rash of acute rheumatic fever

Answer

Occurs only in patients with carditis

Question 7

What maternal condition should be evaluated in a fetus diagnosed with congenital heart block?

Accepted Answer

Systemic lupus erythematosus

Answer

Antiphospholipid syndrome

Answer

Congenital heart defects

Answer

Hemolytic anemia

Question 8

What is the most common presentation of a double aortic arch in infants?

Accepted Answer

Tracheal compression symptoms

Answer

Dysphagia

Answer

Positional hyperemia with right upper arm edema

Answer

Bleeding

Question 9

Which of the following statements is NOT true about Tetralogy of Fallot (TOF)?

Accepted Answer

Atrial septal defect is one of the components of TOF.

Answer

It is the most common congenital cyanotic heart disease in children.

Answer

The severity of the disease depends on the severity of pulmonary stenosis.

Answer

A boot-shaped heart is seen on chest X-ray.

Question 10

Which of the following can cause recurrent pulmonary infections, except?

Accepted Answer

Tetralogy of Fallot (TOF)

Answer

Ventricular Septal Defect (VSD)

Answer

Recurrent lower respiratory tract infections

Answer

Atrial Septal Defect (ASD)

Cardiology — MCQs

Cardiology — MCQs

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