Cardiology Practice Questions

Q: A 50-year-old smoker comes with complaints of ankle edema for last 3 months. The ECG shows all except: (Recent NEET Pattern 2016-17)

Right bundle branch block. ***Right bundle branch block*** - This ECG does **NOT** show features of right bundle branch block, which would require a **wide QRS (≥120 ms)** with an **RSR' (M-shaped) pattern in V1-V3** and wide, slurred S waves in lateral leads (I, V5-V6). - In cor pulmonale, the QRS is typically **narrow** without the RBBB morphology, making RBBB the finding that is **absent** — the correct "EXCEPT" answer. *P pulmonale* - The P waves in leads II, III, and aVF are **tall and peaked** (amplitude ≥2.5 mm in lead II), characteristic of **P pulmonale**, indicating right atrial enlargement/increased right atrial pressure. - This is consistent with **cor pulmonale** from chronic obstructive pulmonary disease (COPD) in a long-term smoker presenting with ankle edema. *Right axis deviation* - The QRS complex is **predominantly negative in lead I** and **positive in aVF**, indicating a **right axis deviation** (axis > +90°). - This reflects **right ventricular hypertrophy or strain**, classic in cor pulmonale due to COPD-induced pulmonary hypertension. *Left axis deviation* - The ECG shows **right axis deviation**, not left axis deviation. - Left axis deviation (axis −30° to −90°) would show a **predominantly positive QRS in lead I and negative in aVF** — the opposite of what is seen here. - Left axis deviation is therefore **NOT present** on this ECG; it is a distracter option. *T wave inversion in II, III, V1-V2* - The ECG shows **T wave inversions** in leads II, III, and V1-V2. - These inversions over the inferior and right precordial leads reflect **right ventricular strain/hypertrophy**, a well-recognised pattern in cor pulmonale.

Q: A 60-year-old hypertension patient presents with breathlessness. ECG was performed. What is the diagnosis? (Recent NEET Pattern 2016-17)

Left ventricular hypertrophy. ***Left ventricular hypertrophy*** - The ECG shows significantly **increased QRS voltage in leads V1-V6**, particularly prominent R waves in V5/V6 and deep S waves in V1/V2, indicating left ventricular hypertrophy as per criteria like **Sokolow-Lyon index** (S in V1 + R in V5/V6 > 35mm). - The presence of **T-wave inversion and ST depression** (strain pattern) in lateral leads (V5, V6), especially in a patient with **hypertension**, further supports the diagnosis of left ventricular hypertrophy. *LBBB* - **LBBB** (Left Bundle Branch Block) is characterized by a **wide QRS complex** (>120 ms) with a **notched or slurred R wave** in lateral leads (I, aVL, V5, V6) and a deep S wave in V1, none of which are definitively seen here. - The QRS duration is not significantly widened, and the morphology is not typical for LBBB. *Normal tracing* - This ECG is not normal due to the **grossly elevated QRS voltages** in precordial leads and the presence of **ST-T wave abnormalities** (strain pattern). - A normal ECG would not exhibit such pronounced voltage criteria for chamber enlargement. *Complete heart block* - Complete heart block is characterized by **dissociation between atrial (P waves) and ventricular (QRS complexes) activity**, where P waves and QRS complexes occur independently. - This ECG shows a regular rhythm with P waves followed by QRS complexes, indicating normal AV conduction and **absence of AV dissociation**. *Right ventricular hypertrophy* - **Right ventricular hypertrophy** (RVH) is characterized by **tall R waves in V1-V2** with **right axis deviation** and **deep S waves in V5-V6**. - This ECG shows the opposite pattern (tall R waves in V5-V6 and deep S waves in V1-V2), which is consistent with **left ventricular** rather than right ventricular hypertrophy.

Q: What does the following ECG show?

Delta wave. ***Delta wave*** - The ECG shows a **short PR interval** and a **slurring upstroke of the QRS complex**, known as a delta wave. - This pattern is characteristic of **Wolff-Parkinson-White (WPW) syndrome**, caused by an accessory pathway that bypasses the AV node, leading to premature ventricular activation. *Osborn wave* - An Osborn wave, or J wave, is a **positive deflection at the J point** (junction of the QRS complex and ST segment), typically seen in **hypothermia**. - This ECG does not show the characteristic prominent J-wave morphology associated with Osborn waves. *Hockey stick sign* - The "hockey stick sign" usually refers to the **downsloping ST segment with a concave upward elevation** seen in conditions like **pericarditis**. - This ECG does not display the characteristic ST segment changes indicative of pericarditis. *Epsilon wave* - An Epsilon wave is a **small, positive deflection embedded in the terminal part of the QRS complex** or immediately after it, primarily seen in **arrhythmogenic right ventricular cardiomyopathy (ARVC)**. - This ECG does not exhibit the small, fragmented depolarization in the terminal QRS characteristic of an epsilon wave. *U wave* - A U wave is a **small deflection that follows the T wave**, most commonly associated with **hypokalemia**, but also seen in conditions like bradycardia or left ventricular hypertrophy. - This ECG does not demonstrate the separate wave following the T wave characteristic of a U wave.

Q: A marathon runner develops occasional missed beats. ECG shows:

Wenckebach phenomenon. ***Wenckebach phenomenon*** - The ECG shows progressive **PR interval prolongation** with each successive beat, followed by a **dropped QRS complex**. This pattern is characteristic of Wenckebach phenomenon, a type of **Mobitz I second-degree AV block**. - Given the patient is a marathon runner, this rhythm can be a benign finding due to **increased vagal tone and athletic conditioning**, leading to occasional missed beats. *Mobitz II heart block* - **Mobitz II heart block** is characterized by consistently normal PR intervals before a sudden, unexpected **dropped QRS complex** without prior PR prolongation. - This type of block is generally considered more serious as it can progress to complete heart block. *Complete heart block* - In **complete heart block (third-degree AV block)**, there is no association between P waves and QRS complexes. Atrial and ventricular rhythms are independent of each other (AV dissociation). - This ECG clearly shows a relationship between P waves (even if progressively prolonged) and QRS complexes before a dropped beat, which is inconsistent with complete heart block. *Sinus bradycardia* - **Sinus bradycardia** is a slow heart rate with a normal rhythm, meaning each P wave is followed by a QRS complex with a consistent PR interval. - While a marathon runner might have a slow baseline heart rate (bradycardia), the presence of **dropped beats** and **PR interval changes** rules out simple sinus bradycardia. *First-degree AV block* - **First-degree AV block** presents with a prolonged PR interval (>200 ms), but **every P wave is followed by a QRS complex** with no dropped beats. - While this can also be seen in conditioned athletes, the presence of **dropped QRS complexes** on this ECG differentiates it from first-degree AV block and indicates Mobitz I (Wenckebach) phenomenon.

Q: A 55-year-old woman with non-ischemic cardiomyopathy presents with palpitations. ECG shows:

Torsades de pointes. ***Torsades de pointes*** - The ECG demonstrates a polymorphic ventricular tachycardia with a characteristic **"twisting of the points"** pattern around the isoelectric line, which is pathognomonic for Torsades de Pointes. - This arrhythmia is often associated with a **prolonged QT interval**, which can be congenital or acquired due to drugs or electrolyte imbalances, and is common in patients with underlying cardiac conditions like cardiomyopathy. *Ventricular tachycardia* - While Torsades de Pointes is a form of ventricular tachycardia, the term "ventricular tachycardia" alone does not capture the specific **polymorphic and twisting morphology** seen on this ECG. - Monomorphic ventricular tachycardia typically exhibits **QRS complexes of uniform shape and amplitude**, which is not seen here. *Bidirectional tachycardia* - **Bidirectional tachycardia** is characterized by alternating QRS axis and morphology, often with a different QRS complex every other beat and an alternating axis. - This pattern is not evident in the provided ECG, which shows a continuous, varying morphology typical of Torsades. *Atrial fibrillation with aberrancy* - **Atrial fibrillation with aberrant conduction** presents with irregularly irregular rhythm and wide QRS complexes due to bundle branch block or rate-related aberrancy. - The ECG shows a **characteristic polymorphic twisting pattern** with a regular ventricular rate, not the irregular rhythm expected with atrial fibrillation. *PSVT* - **Paroxysmal supraventricular tachycardia (PSVT)** involves narrow QRS complexes and originates above the ventricles, typically presenting with heart rates of 150-250 bpm. - The ECG shows **wide, polymorphic QRS complexes**, clearly indicating a ventricular origin rather than supraventricular.

Q: A patient becomes pulseless and his BP crashes after myocardial infarction. Diagnosis is:

Ventricular fibrillation. ***Ventricular fibrillation*** - This ECG shows completely **disorganized electrical activity** with no identifiable QRS complexes, P waves, or T waves, characteristic of ventricular fibrillation. - In ventricular fibrillation, the heart muscle quivers rather than contracts effectively, leading to immediate **pulselessness** and a rapid drop in blood pressure, often after a myocardial infarction. *Monomorphic ventricular tachycardia* - This rhythm typically presents with wide QRS complexes of **uniform morphology** and a rapid, regular rate. - While it can cause hemodynamic instability, the ECG in this case does not show organized wide QRS complexes. *Bidirectional tachycardia* - This is a rare form of ventricular tachycardia characterized by **alternating QRS complex morphologies** in the same lead, which is not seen here. - It is often associated with **digoxin toxicity** or severe heart disease. *Polymorphic ventricular tachycardia* - This rhythm features **wide QRS complexes** that vary in morphology and amplitude, indicating multiple re-entrant pathways. - Although it is a life-threatening arrhythmia, the tracing here is more chaotic and completely disorganized, lacking discernible QRS complexes altogether. *Pulseless electrical activity* - PEA presents with **organized electrical activity** on ECG but **no palpable pulse** or mechanical cardiac output. - The ECG in this case shows **chaotic, disorganized waveforms** without any recognizable complexes, which is inconsistent with PEA.

Q: Identify the arrhythmia shown below:

Atrial flutter. ***Atrial flutter*** * The image shows characteristic **sawtooth flutter waves** with a regular ventricular response, indicative of atrial flutter. * There are no identifiable P waves, but instead, regularly occurring **F waves** are seen, typically at a rate of 250-350 bpm. *Atrial fibrillation* * Atrial fibrillation is characterized by **irregularly irregular rhythm** and the absence of distinct P waves, replaced by chaotic fibrillatory waves. * The image clearly shows regular ventricular beats and visible, organized, albeit abnormal, atrial activity. *Multifocal atrial tachycardia* * MAT is characterized by at least **three different P wave morphologies** and an irregular atrial rhythm. * The tracing shows continuous, uniform flutter waves rather than varying P wave shapes or an irregular rhythm. *Paroxysmal atrial tachycardia* * PAT typically presents as an abrupt onset and termination of a rapid, regular heart rhythm originating from an ectopic focus in the atria. * While it involves rapid atrial activity, PAT is usually characterized by distinct, monomorphic P waves that precede each QRS complex, unlike the sawtooth pattern seen here. *Sinus tachycardia* * Sinus tachycardia shows a **regular rhythm with normal P waves** preceding each QRS complex, with a 1:1 AV relationship. * The characteristic **sawtooth flutter waves** seen in this tracing are distinctly different from the normal P wave morphology expected in sinus tachycardia.

Q: A 68 -year-old man presents with symptoms of alcohol withdrawal. ECG shows:

Atrial fibrillation. ***Atrial fibrillation*** - The ECG shows a **chaotic, irregular baseline with no discernible P waves**, which is characteristic of atrial fibrillation. - The ventricular rhythm is **irregularly irregular**, with varying R-R intervals, further confirming the diagnosis. - Atrial fibrillation is commonly associated with **alcohol withdrawal** (holiday heart syndrome), making this the most likely diagnosis in this clinical context. *Atrial flutter* - This rhythm is characterized by regular, sawtooth-shaped **F waves** in leads II, III, and aVF, which are absent in this ECG. - While it can also lead to a rapid ventricular rate, the atrial activity is organized, unlike the chaotic activity seen here. *PSVT* - PSVT typically presents with a **regular, narrow-complex tachycardia** with a sudden onset and termination. - The chaotic atrial activity and irregularly irregular ventricular rhythm seen in the ECG are not consistent with PSVT. *VT* - Ventricular tachycardia is characterized by a **wide-complex tachycardia**, often regular, originating from the ventricles. - The ECG shows **narrow QRS complexes** and chaotic atrial activity, ruling out VT. *Multifocal atrial tachycardia* - MAT shows at least **three distinct P wave morphologies** with varying PR intervals, creating an irregularly irregular rhythm. - However, **P waves are identifiable** in MAT, whereas this ECG shows **no discernible P waves** with a chaotic baseline, making atrial fibrillation the correct diagnosis.

Question 1

A healthy 36-year-old corporate executive has an ECG performed as part of annual health check-up. He is asymptomatic. ECG shows:

Accepted Answer

Early repolarization variant

Answer

ST segment depression in chest leads

Answer

Delta wave

Answer

J wave

Answer

Acute pericarditis

Question 2

A 50-year-old smoker comes with complaints of ankle edema for last 3 months. The ECG shows all except: (Recent NEET Pattern 2016-17)

Accepted Answer

Right bundle branch block

Answer

P pulmonale

Answer

Right axis deviation

Answer

T wave inversion in II,III, V1-V2

Answer

Left axis deviation

Question 3

A 60-year-old hypertension patient presents with breathlessness. ECG was performed. What is the diagnosis? (Recent NEET Pattern 2016-17)

Accepted Answer

Left ventricular hypertrophy

Answer

LBBB

Answer

Normal tracing

Answer

Complete heart block

Answer

Right ventricular hypertrophy

Question 4

What does the following ECG show?

Accepted Answer

Delta wave

Answer

Osborn wave

Answer

Hockey stick sign

Answer

Epsilon wave

Answer

U wave

Question 5

A marathon runner develops occasional missed beats. ECG shows:

Accepted Answer

Wenckebach phenomenon

Answer

Mobitz II heart block

Answer

Complete heart block

Answer

Sinus bradycardia

Answer

First-degree AV block

Question 6

A 55-year-old woman with non-ischemic cardiomyopathy presents with palpitations. ECG shows:

Accepted Answer

Torsades de pointes

Answer

Ventricular tachycardia

Answer

Bidirectional tachycardia

Answer

PSVT

Answer

Atrial fibrillation with aberrancy

Question 7

A patient becomes pulseless and his BP crashes after myocardial infarction. Diagnosis is:

Accepted Answer

Ventricular fibrillation

Answer

Monomorphic ventricular tachycardia

Answer

Bidirectional tachycardia

Answer

Polymorphic ventricular tachycardia

Answer

Pulseless electrical activity

Question 8

Identify the arrhythmia shown below:

Accepted Answer

Atrial flutter

Answer

Atrial fibrillation

Answer

Multifocal atrial tachycardia

Answer

Paroxysmal atrial tachycardia

Answer

Sinus tachycardia

Question 9

A 68 -year-old man presents with symptoms of alcohol withdrawal. ECG shows:

Accepted Answer

Atrial fibrillation

Answer

Atrial flutter

Answer

PSVT

Answer

VT

Answer

Multifocal atrial tachycardia

Question 10

Comment on the diagnosis from the ECG shown below:

Accepted Answer

2:1 heart block

Answer

Trifascicular block

Answer

First degree heart block

Answer

Atrial fibrillation

Answer

Complete heart block

Cardiology — MCQs

Cardiology — MCQs

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