Cardiology Practice Questions

Q: A patient had an occlusion of the artery marked as " A " in the given image. Which part of the heart is most likely affected?

Anterior wall. ***Anterior wall*** - Occlusion of the **Left Anterior Descending (LAD) artery**—typically responsible for supplying the anterior wall of the left ventricle and the anterior two-thirds of the interventricular septum—leads to **anterior wall myocardial infarction**. - This is a common and clinically significant infarct pattern often associated with **ST-segment elevation** in leads **V1–V4** on an ECG. *Posterior wall* - The posterior wall of the heart is usually supplied by the **left circumflex artery (LCx)** or the **posterior descending artery (PDA)**, depending on **coronary dominance**. - Infarction here typically manifests as ST elevation in leads **V7–V9** and is often associated with involvement of the lateral or inferior walls. *Inferior wall* - The inferior wall of the heart is primarily supplied by the **Right Coronary Artery (RCA)** in the majority of individuals (right-dominant circulation). - An isolated inferior wall myocardial infarction typically results in ST-segment elevation in leads **II, III, and aVF**. *Lateral wall* - The lateral wall of the left ventricle is typically supplied by branches of the **left circumflex artery (LCx)**, specifically the **obtuse marginal branches**. - Infarction of the lateral wall often correlates with ST-segment changes in leads **I, aVL, V5, and V6**.

Q: A patient presents with complaints of shortness of breath and effort intolerance. On auscultation a loud opening snap with mid diastolic murmur is heard. Echocardiography shows an EF of 38%. ECG is shown below. Diagnosis is?

Critical mitral stenosis. ***Critical mitral stenosis*** - A **loud opening snap** followed by a **mid-diastolic murmur** is the classic auscultatory finding of **mitral stenosis**, caused by the sudden tensing of the mitral valve leaflets upon opening. - The clinical presentation of **shortness of breath** and **effort intolerance** suggests elevated **left atrial pressure** and resultant pulmonary congestion, hallmarks of mitral stenosis severity. *Aortic stenosis* - Characterized by a **systolic ejection murmur** that radiates to the carotids, rather than a **mid-diastolic murmur**. - Typically presents with a **pulsus parvus et tardus** (weak and delayed carotid upstroke), which is not described here. *Mitral Regurgitation* - Presents with a **holosystolic murmur** heard best at the apex, radiating to the axilla, differing from the diastolic murmur seen in mitral stenosis. - Because blood flows back into the left atrium during systole, you would not expect an **opening snap**. *Aortic regurgitation* - Presents with an **early diastolic decrescendo murmur** best heard at the left sternal border. - It is frequently associated with a **wide pulse pressure** and **water-hammer pulse**, contrasting with the obstructive clinical picture of this patient.

Q: You are asked to assess the pulse tracing of the patient. The following pulse corresponds to involvement of which of the following heart valves?

Aortic valve. ***Aortic valve*** - The arterial pulse tracing is a direct reflection of left ventricular outflow, making it the primary diagnostic indicator for **aortic valve disease** such as **aortic stenosis** (resulting in *pulsus parvus et tardus*) or **aortic regurgitation** (resulting in *collapsing pulse* or *water-hammer pulse*). - Morphological changes in the waveform, such as a **bisferiens pulse**, are classic findings associated specifically with combined aortic stenosis and insufficiency. *Mitral valve* - Mitral valve pathology typically presents with specific auscultatory findings, such as a **holosystolic murmur** or **mid-systolic click**, rather than characteristic arterial pulse abnormalities. - While severe, chronic mitral regurgitation may eventually lead to reduced cardiac output, it does not produce a specific, diagnostic arterial pulse wave morphology. *Tricuspid valve* - Tricuspid valve involvement is best assessed through **jugular venous pulse (JVP)** analysis, specifically looking for abnormal 'v' waves or systolic 'c-v' waves, rather than the peripheral arterial pulse. - Peripheral arterial pulse tracings are generally unaffected by tricuspid regurgitation or stenosis, as the right-sided circulation is separated from the systemic arterial bed. *Pulmonary valve* - Pulmonary valve pathology, such as **pulmonary stenosis**, manifests primarily as an abnormal jugular venous 'a' wave or right ventricular heave, not changes in the peripheral arterial pulse. - The arterial pulse remains essentially normal in pulmonary valve disease because the obstruction is located in the right heart, occurring before the blood reaches the pulmonary or systemic circulation.

Q: Middle aged male presented with gradually progressive effort intolerance and awareness of forceful heartbeats over the last few moths. On geneal physical examination, there is a visibly strong, bounding pulasation in the neck with prominent carotid upstroke. Careful inspection of the nail beds reveals rhythmic pulsatile blanching synchronous with cardiac cycle. Which of the following auscultatory findings best corresponds to this clinical presentation?

Early diastolic murmur. ***Early diastolic murmur*** - The patient exhibits classic signs of **chronic aortic regurgitation (AR)**, including a **bounding pulse** (water-hammer pulse) and **Quincke's pulse** (pulsatile capillary blanching under nail beds). - The hallmark auscultatory finding in **aortic regurgitation** is a high-pitched, blowing **early diastolic murmur** best heard at the left sternal border. *Late diastolic murmur* - This finding is classically associated with **mitral stenosis**, often described as a **presystolic accentuation**. - It does not correlate with the peripheral vascular findings of increased stroke volume and rapid runoff seen in **aortic regurgitation**. *Systolic crescendo decresendo* - This murmur is the classic presentation of **aortic stenosis**, typically heard at the right upper sternal border. - Unlike AR, **aortic stenosis** presents with a **pulsus parvus et tardus** (weak and delayed pulse), which contradicts the bounding pulse described. *Mid systolic murmur* - Often heard in conditions like **mitral valve prolapse** (associated with a click) or benign **flow murmurs**. - It lacks the diastolic timing required to explain the significant high-pressure jet refluxing from the aorta into the left ventricle during diastole.

Q: A 58-year-old man presents to the emergency department with sudden onset severe retrosternal chest pain associated with diaphoresis and nausea. ECG shows ST elevation in leads II, III, aVF. His BP is 80/60 mmHg with cool extremities, but lung fields clear on ausculataion. What is the next best step in management?

IV normal saline. ***IV normal saline*** - This patient has an **inferior wall myocardial infarction** (ST elevation in II, III, aVF) complicated by **hypotension** and **clear lung fields**, which is highly suggestive of **Right Ventricular (RV) Infarction**. - The right ventricle is **preload-dependent**; therefore, initial management requires **aggressive fluid resuscitation** with intravenous normal saline to optimize preload and cardiac output. *Nitroglycerine* - Nitroglycerin is a **venodilator** that decreases preload, which can cause severe, life-threatening **hypotension** in patients with RV infarction. - It should be strictly avoided in patients with right-sided heart involvement until right ventricular preload is adequately restored. *Diuretics* - Diuretics decrease intravascular volume and would worsen the **hypotension** already present in this patient. - They are contraindicated in acute RV infarction, regardless of the presence of peripheral edema, due to the need to maintain preload. *Vasopressors* - Vasopressors are considered only if the patient remains hypotensive after **adequate fluid resuscitation** and is unresponsive to volume loading. - Starting vasopressors before optimizing preload can exacerbate ischemia and myocardial work, making fluids the primary first-line intervention.

Q: A 38-year-old male presents with sudden onset palpitations. He has no known comorbidities and his vitals are stable. ECG shows an irregularly irregular rhythm with no identifiable P waves and a ventricular rate of 130 beats per minute. What is the most likely diagnosis?

Atrial fibrillation. ***Atrial fibrillation*** - Characterized by an **irregularly irregular rhythm** and the complete absence of **discrete P waves**, which is the hallmark ECG finding. - The atria undergo rapid, chaotic electrical activity, leading to varying ventricular response rates, such as the **130 beats per minute** seen in this patient. *Multifocal atrial tachycardia* - Requires the presence of at least **three distinct P-wave morphologies** on ECG, which contradicts the finding of "no identifiable P waves." - Usually associated with severe **chronic obstructive pulmonary disease (COPD)** rather than isolated idiopathic presentation in healthy individuals. *Atrial flutter* - Typically displays a **regular (or regularly irregular)** rhythm with a classic **'sawtooth'** pattern of atrial activity. - Represents a form of macro-reentrant tachycardia rather than the chaotic, disorganized electrical activity seen in fibrillation. *Supraventricular tachycardia* - Typically presents as a **regular, narrow-complex tachycardia** with a sudden onset and offset. - Unlike the irregular rhythm described, SVT (such as AVNRT) usually maintains a fixed rhythm without the beat-to-beat variability characteristic of atrial fibrillation.

Q: In which of the following conditions is cyanosis most likely to be a clinical finding?

Eisenmenger syndrome. ***Eisenmenger syndrome*** - This condition represents the late stage of a **left-to-right shunt** where chronic pulmonary hypertension leads to increased pulmonary vascular resistance, causing the shunt to reverse into a **right-to-left shunt**. - The resulting **deoxygenated blood** enters the systemic circulation directly, causing profound, clinically apparent **central cyanosis**. *Atrioventricular septal defect* - In children, this often presents as a **left-to-right shunt** leading to **pulmonary overcirculation** and symptoms of congestive heart failure, rather than cyanosis. - Cyanosis only occurs in this condition if it progresses to the Eisenmenger stage or is associated with complex defects like **Tetralogy of Fallot**. *Partial anomalous pulmonary venous connection* - This is primarily an **acyanotic** congenital heart defect where pulmonary veins drain into systemic veins or the right atrium, leading to **pulmonary overcirculation**. - There is no right-to-left shunting of deoxygenated blood into the systemic circulation, so patients typically do not manifest **cyanosis**. *Advanced aortic stenosis* - This condition causes **left ventricular outflow tract obstruction**, leading to symptoms like **syncope, angina, and dyspnea** due to low cardiac output. - While patients may appear pale or gray due to **hypoperfusion**, they do not develop central cyanosis, as the defect is not related to systemic **deoxygenated blood shunting**.

Q: A 58-year-old male presents with crushing chest pain radiating to the jaw. His ECG reveals ST- segment elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

Right coronary artery. ***Right coronary artery*** - ST-segment elevation in leads II, III, and aVF indicates an **inferior wall myocardial infarction**, which is most commonly supplied by the **Right Coronary Artery (RCA)** in right-dominant circulation. - Occlusion of the RCA can lead to bradycardias or heart blocks due to ischemia of the **AV node**, which is typically supplied by the RCA. *Posterior descending artery* - While the **Posterior Descending Artery (PDA)** supplies the inferior wall of the heart, it is usually a distal branch of the RCA (in right-dominant circulation) rather than the primary vessel involved in an acute occlusion leading to this pattern. - An isolated occlusion of the PDA is less common than an occlusion of the proximal or mid-RCA that also involves the right ventricular branches. *Left circumflex artery* - The **Left Circumflex Artery (LCx)** typically supplies the lateral wall of the heart, corresponding to ECG leads I, aVL, V5, and V6. - Occlusion of the LCx would likely present with ST elevations in the **lateral leads** rather than the inferior leads observed in this patient. *Anterior interventricular artery* - Also known as the Left Anterior Descending (LAD) artery, this vessel supplies the **anterior wall** and the apex of the heart. - Occlusion of the LAD typically manifests as ST elevations in leads **V1–V4**, not the inferior leads (II, III, aVF) seen in this case.

Q: A 62-year-old hypertensive male presents to the emergency department with sudden-onset tearing chest pain radiating to the back. BP is 180/110 mmHg in the right arm and 150/90 mmHg in the left arm. ECG shows no ST changes. The patient is hemodynamically stable. The chest X-ray is shown in Image 2. What is the most appropriate immediate next investigation?

A. CT aortography with intravenous contrast. ***A. CT aortography with intravenous contrast*** - In a **hemodynamically stable** patient with tearing chest pain, blood pressure disparity, and **mediastinal widening**, CT aortography is the gold standard for rapid confirmation. - It accurately identifies the **intimal flap**, determines the **Stanford classification**, and evaluates involvement of major arterial branches for surgical planning. *B. Transthoracic echocardiography* - While useful at the bedside, it has low sensitivity for the **descending aorta** and may miss a **Stanford Type B** dissection. - It is generally reserved for **unstable patients** in the emergency room or as a supplement to identify complications like **aortic regurgitation** or **pericardial effusion**. *C. Ventilation-perfusion scintigraphy* - This investigation is used to diagnose **pulmonary embolism** and has no role in the evaluation of the **aorta**. - The clinical presentation of **tearing pain radiating to the back** and asymmetric pulses is highly specific for **aortic dissection** rather than a pulmonary cause. *D. Coronary CT angiography* - This modality is optimized for visualizing the **coronary arteries** and does not provide the comprehensive field of view required to assess the entire length of the **aorta**. - It lacks the specific **bolus timing** and scan range necessary to adequately map a **dissection flap** from the arch through the abdomen.

Question 1

A patient had an occlusion of the artery marked as " A " in the given image. Which part of the heart is most likely affected?

Accepted Answer

Anterior wall

Answer

Posterior wall

Answer

Inferior wall

Answer

Lateral wall

Question 2

A patient presents with complaints of shortness of breath and effort intolerance. On auscultation a loud opening snap with mid diastolic murmur is heard. Echocardiography shows an EF of 38%. ECG is shown below. Diagnosis is?

Accepted Answer

Critical mitral stenosis

Answer

Aortic stenosis

Answer

Mitral Regurgitation

Answer

Aortic regurgitation

Question 3

You are asked to assess the pulse tracing of the patient. The following pulse corresponds to involvement of which of the following heart valves?

Accepted Answer

Aortic valve

Answer

Mitral valve

Answer

Tricuspid valve

Answer

Pulmonary valve

Question 4

Middle aged male presented with gradually progressive effort intolerance and awareness of forceful heartbeats over the last few moths. On geneal physical examination, there is a visibly strong, bounding pulasation in the neck with prominent carotid upstroke. Careful inspection of the nail beds reveals rhythmic pulsatile blanching synchronous with cardiac cycle. Which of the following auscultatory findings best corresponds to this clinical presentation?

Accepted Answer

Early diastolic murmur

Answer

Late diastolic murmur

Answer

Systolic crescendo decresendo

Answer

Mid systolic murmur

Question 5

A 58-year-old man presents to the emergency department with sudden onset severe retrosternal chest pain associated with diaphoresis and nausea. ECG shows ST elevation in leads II, III, aVF. His BP is 80/60 mmHg with cool extremities, but lung fields clear on ausculataion. What is the next best step in management?

Accepted Answer

IV normal saline

Answer

Nitroglycerine

Answer

Diuretics

Answer

Vasopressors

Question 6

A 38-year-old male presents with sudden onset palpitations. He has no known comorbidities and
his vitals are stable. ECG shows an irregularly irregular rhythm with no identifiable P waves and a
ventricular rate of 130 beats per minute. What is the most likely diagnosis?

Accepted Answer

Atrial fibrillation

Answer

Multifocal atrial tachycardia

Answer

Atrial flutter

Answer

Supraventricular tachycardia

Question 7

In which of the following conditions is cyanosis most likely to be a clinical finding?

Accepted Answer

Eisenmenger syndrome

Answer

Atrioventricular septal defect

Answer

Partial anomalous pulmonary venous connection

Answer

Advanced aortic stenosis

Question 8

A 58-year-old male presents with crushing chest pain radiating to the jaw. His ECG reveals ST-
segment elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

Accepted Answer

Right coronary artery

Answer

Posterior descending artery

Answer

Left circumflex artery

Answer

Anterior interventricular artery

Question 9

A 62-year-old hypertensive male presents to the emergency department with sudden-onset tearing chest pain radiating to the back. BP is 180/110 mmHg in the right arm and 150/90 mmHg in the left arm. ECG shows no ST changes. The patient is hemodynamically stable. The chest X-ray is shown in Image 2. What is the most appropriate immediate next investigation?

Accepted Answer

A. CT aortography with intravenous contrast

Answer

B. Transthoracic echocardiography

Answer

C. Ventilation-perfusion scintigraphy

Answer

D. Coronary CT angiography

Question 10

A 45-year-old man with no prior medical history presents to the emergency department with a 3-day history of severe headache, blurred vision, and nausea. His blood pressure is 240/140 mmHg. Neurological examination is intact. Fundoscopy is performed (Image 1). Which of the following is the most appropriate immediate management target for blood pressure reduction over the first hour?

Accepted Answer

A. Reduce mean arterial pressure (MAP) by no more than 25% within the first hour using intravenous labetalol or nicardipine

Answer

B. Achieve a target blood pressure of less than 120/80 mmHg within the first hour using intravenous sodium nitroprusside

Answer

C. Reduce systolic blood pressure to below 160 mmHg within 15 minutes using sublingual nifedipine

Answer

D. Reduce MAP by 40–50% within the first hour using intravenous hydralazine to prevent further end-organ damage

Cardiology — MCQs

Cardiology — MCQs

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