Non-invasive Cardiac Diagnostics — MCQs
Investigation of choice for valvular heart disease-
Most sensitive method of monitoring cardiovascular ischemia in the perioperative period is -
In which lead is the normal P wave inverted?
A young female presents with chest pain not associated with exercise. Auscultation reveals multiple ejection clicks with a murmur. The most important investigation for diagnosis is:
MRI is superior in all of the following conditions except
The patient presented with a retroverted uterus, dysmenorrhea, and dyspareunia. What is the next step of the investigation?
Which condition is indicated by ST segment elevation in leads V1-V4?
Identify the diagnosis based on the provided ECG image.
What is the most likely cause of fluid overload in a patient presenting with shortness of breath?
Which drug is used as an adjunct to epinephrine in refractory ventricular fibrillation/ventricular tachycardia during cardiac arrest?
Non-invasive Cardiac Diagnostics Indian Medical PG Practice Questions and MCQs
Question 1: Investigation of choice for valvular heart disease-
- A. Nuclear Cardiac imaging
- B. Precordial Doppler
- C. 2 D- Echocardiography (Correct Answer)
- D. MRI
Explanation: ***2 D- Echocardiography*** - **Transthoracic echocardiography (TTE)** is the initial and most common investigation for valvular heart disease due to its non-invasiveness, accessibility, and ability to visualize valve morphology and function in real-time [1]. - It provides critical information on valve structure, leaflet motion, chamber dimensions, ventricular function, and pressure gradients, allowing diagnosis and assessment of severity [2]. *Nuclear Cardiac imaging* - Primarily used for assessing **myocardial perfusion** and viability, rather than direct visualization of valve structure and function. - While it can indirectly assess the impact of valvular disease on ventricular function, it does not provide detailed information about the valves themselves. *Precordial Doppler* - **Doppler echocardiography** is a component of a full echocardiogram, used to quantify blood flow velocities and pressure gradients across valves [1]. - However, "precordial Doppler" is not a standalone comprehensive investigation for valvular disease; it must be combined with 2D imaging for a complete assessment. *MRI* - **Cardiac MRI (CMR)** offers excellent anatomical detail and precise quantification of ventricular volumes and function, and can assess valvular regurgitation. - It is often used as a complementary study in specific cases, particularly for complex congenital heart disease or when echocardiography is inconclusive, but it is not the primary or initial investigation due to cost and accessibility.
Question 2: Most sensitive method of monitoring cardiovascular ischemia in the perioperative period is -
- A. NIBP
- B. ECG
- C. Pulse oximeter
- D. TEE (Correct Answer)
Explanation: ***TEE*** - **Transesophageal echocardiography (TEE)** is the most sensitive method for detecting perioperative myocardial ischemia because it can visualize **regional wall motion abnormalities** and changes in **ventricular function** much earlier than ECG. - **Ischemia** directly impairs the contractility of the affected myocardium, leading to subtle changes in wall motion that TEE can identify. *NIBP* - **Non-invasive blood pressure (NIBP)** monitoring can detect **hemodynamic changes** (like hypotension or hypertension) that may precede or accompany ischemia. - However, these changes are **non-specific** and occur relatively late, making NIBP a less sensitive indicator of early ischemia. *ECG* - **Electrocardiography (ECG)** monitors the electrical activity of the heart and can detect **ST-segment changes** indicative of ischemia. - While useful, ECG changes may appear later than wall motion abnormalities, and **silent ischemia** can be missed if the leads are not optimally placed or if the ischemia does not produce significant electrical changes. *Pulse oximeter* - A **pulse oximeter** measures **oxygen saturation** in the peripheral blood. - It is primarily used to assess **respiratory function** and tissue oxygenation, and it does not directly monitor myocardial ischemia or cardiac function.
Question 3: In which lead is the normal P wave inverted?
- A. LI
- B. LII
- C. aVF
- D. aVR (Correct Answer)
Explanation: **Correct: *aVR*** - In lead **aVR**, the electrical activity is recorded from the perspective of the **right arm** towards the left foot and arm. Since the P wave represents atrial depolarization, which normally originates in the **sinoatrial node** in the right atrium and spreads leftward and inferiorly, the impulse moves away from the positive electrode of aVR. - This movement away from aVR's positive electrode causes a **negative (inverted)** deflection, which is a normal finding for the P wave in this lead. *Incorrect: LI* - Lead I records electrical activity between the **right arm (negative)** and the **left arm (positive)**. - As atrial depolarization moves towards the left arm, the P wave is normally **upright** in lead I. *Incorrect: LII* - Lead II records electrical activity between the **right arm (negative)** and the **left leg (positive)**. - Because atrial depolarization (from SA node) spreads downwards and to the left, it moves predominantly towards the positive electrode of lead II, resulting in an **upright** P wave. *Incorrect: aVF* - Lead aVF records electrical activity towards the **left foot (positive)**, providing an inferior view of the heart. - Since atrial depolarization moves inferiorly towards the left leg, the P wave in aVF is typically **upright**.
Question 4: A young female presents with chest pain not associated with exercise. Auscultation reveals multiple ejection clicks with a murmur. The most important investigation for diagnosis is:
- A. ECG
- B. Thallium 201 scan
- C. Echocardiography (Correct Answer)
- D. Tc pyrophosphate scan
Explanation: ***Echocardiography*** - **Echocardiography** is the gold standard for visualizing cardiac structures and valve function, allowing direct assessment of **mitral valve prolapse (MVP)** [1]. - The presence of **multiple ejection clicks** and a murmur in a young female with non-exertional chest pain strongly suggests MVP, which can be confirmed by echocardiography [3]. *ECG* - An **ECG** can detect arrhythmias or signs of ischemia, but it cannot directly visualize the heart valves or diagnose **mitral valve prolapse** [2]. - While some MVP patients may have T-wave abnormalities or QT prolongation, these findings are non-specific and not diagnostic. *Thallium 201 scan* - A **Thallium 201 scan** is a nuclear imaging test primarily used to assess myocardial perfusion and detect areas of ischemia, usually in the context of **coronary artery disease** [4]. - It does not provide detailed anatomical information about heart valves or cardiac chamber morphology, making it unsuitable for diagnosing **mitral valve prolapse**. *Tc pyrophosphate scan* - A **Tc pyrophosphate scan** is primarily used to diagnose **amyloidosis** or evaluate myocardial infarction, particularly for detecting late-phase complications or right ventricular involvement. - It does not offer direct visualization of valvular structures and is not indicated for the diagnosis of **mitral valve prolapse**.
Question 5: MRI is superior in all of the following conditions except
- A. Diagnosis of iron overload cardiomyopathy in a pediatric patient with β-thalassemia major and congestive heart failure.
- B. Serial evaluation of liver functions in a 54-year-old female with metastatic carcinoma breast with doxorubicin chemotherapy (Correct Answer)
- C. Diagnosis of aortic coarctation in a 17-year-old female with hypertension and radiofemoral delay on physical examination.
- D. Diagnosis of arrhythmogenic right ventricular cardiomyopathy in a 24-year-old man who survived recent cardiac arrest.
Explanation: ***Serial evaluation of liver functions in a 54-year-old female with metastatic carcinoma breast with doxorubicin chemotherapy*** - While MRI can assess **liver morphology** and some functional parameters, **liver function** is primarily evaluated through **blood tests** (e.g., liver enzymes, bilirubin, albumin). - Regular biochemical tests are more direct and efficient for monitoring liver function during chemotherapy. *Diagnosis of iron overload cardiomyopathy in a pediatric patient with β-thalassemia major and congestive heart failure.* - **Cardiac MRI with T2* mapping** is the gold standard for quantifying myocardial iron deposition, which leads to iron overload cardiomyopathy. - This is crucial for guiding chelation therapy and preventing irreversible heart damage in **thalassemia patients**. *Diagnosis of aortic coarctation in a 17-year-old female with hypertension and radiofemoral delay on physical examination.* - **MRI angiography** provides excellent detailed anatomical imaging of the aorta, including the site, extent, and severity of coarctation, as well as collateral circulation. - This offers a comprehensive assessment that is superior to echocardiography in older children and adults. *Diagnosis of arrhythmogenic right ventricular cardiomyopathy in a 24-year-old man who survived recent cardiac arrest.* - **Cardiac MRI** is highly effective in diagnosing **ARVC** by detecting characteristic findings such as **fibrofatty replacement** in the right ventricular myocardium, wall motion abnormalities, and regional aneurysms. - These features are often difficult to visualize with other imaging modalities.
Question 6: The patient presented with a retroverted uterus, dysmenorrhea, and dyspareunia. What is the next step of the investigation?
- A. HSG
- B. USG (Correct Answer)
- C. Laparotomy
- D. Diagnostic Laparoscopy
Explanation: ***USG*** - **Transvaginal ultrasound (TVS)** is the initial imaging modality of choice for evaluating uterine position, assessing for causes of dysmenorrhea and dyspareunia (e.g., **endometriosis**, adenomyosis, fibroids), and can visualize the retroverted uterus. - It is **non-invasive**, readily available, and provides good resolution of pelvic organs, making it suitable for first-line investigation. *HSG* - **Hysterosalpingography (HSG)** is primarily used to assess **fallopian tube patency** in cases of infertility. - It will **not provide detailed information** about the uterine position or other pelvic pathologies contributing to pain. *Laparotomy* - **Laparotomy** is a major surgical procedure involving a large abdominal incision, typically reserved for **definitive diagnosis and treatment** of significant pelvic pathology when less invasive methods are insufficient. - It is **not an initial investigatory step** for symptoms like dysmenorrhea and dyspareunia. *Diagnostic Laparoscopy* - **Diagnostic laparoscopy** is a minimally invasive surgical procedure that allows direct visualization of pelvic organs, often used to **confirm endometriosis** or other pathologies. - While it offers definitive diagnosis, it is an **invasive procedure** and usually performed **after initial non-invasive imaging** (like USG) has been completed.
Question 7: Which condition is indicated by ST segment elevation in leads V1-V4?
- A. Posterior myocardial infarction
- B. Lateral myocardial infarction
- C. Anterior myocardial infarction (Correct Answer)
- D. Inferior myocardial infarction
Explanation: ***Anterior myocardial infarction*** - **ST segment elevation** in leads **V1-V4** is indicative of an infarction in the **anterior wall** of the left ventricle [1]. - These leads correspond to the distribution of the **left anterior descending (LAD) coronary artery**, which supplies the anterior wall and septum [2]. *Posterior myocardial infarction* - This typically presents with **ST depression** in **V1-V4**, along with tall R waves and prominent T waves in the same leads, due to a reciprocal change. - Definitive diagnosis requires **posterior leads (V7-V9)**, which would show ST elevation. *Lateral myocardial infarction* - Characterized by **ST elevation** in leads **I, aVL, V5, and V6**, reflecting ischemia in the lateral wall of the left ventricle [1]. - These leads are supplied by the **circumflex artery** or a diagonal branch of the LAD. *Inferior myocardial infarction* - Identified by **ST elevation** in leads **II, III, and aVF**, indicating involvement of the inferior wall [1]. - This is typically caused by occlusion of the **right coronary artery (RCA)** or a dominant circumflex artery.
Question 8: Identify the diagnosis based on the provided ECG image.
- A. VT
- B. PSVT (Correct Answer)
- C. AT
- D. Ventricular fibrillation
Explanation: ***PSVT*** - The ECG shows a **narrow complex tachycardia** with a regular rhythm and a high heart rate, characteristic of **paroxysmal supraventricular tachycardia (PSVT)**. - P waves are often **buried within the QRS complex** or T waves, or may be retrograde, which can be seen as small deflections or changes in the baseline in some leads. *VT* - **Ventricular tachycardia** is characterized by a **wide QRS complex** (>0.12 seconds), which is not observed in this ECG. - While VT can be regular, the primary distinguishing feature is the QRS duration. *AT* - **Atrial tachycardia (AT)** is another form of supraventricular tachycardia, but it typically shows **distinct P waves** with an abnormal morphology, often separate from the T wave, which are not clearly visible or consistently distinct in this tracing. - While it can present with narrow complex tachycardia, the mechanism differs from re-entrant PSVT. *Ventricular fibrillation* - **Ventricular fibrillation** is characterized by **chaotic, irregular electrical activity** with no distinguishable P waves, QRS complexes, or T waves, representing disorganized ventricular depolarization. - The ECG in the image shows a consistent, regular rhythm with identifiable, albeit narrow, QRS complexes.
Question 9: What is the most likely cause of fluid overload in a patient presenting with shortness of breath?
- A. Nephritic syndrome
- B. Cardiac failure (Correct Answer)
- C. TB
- D. Portal hypertension
Explanation: ***Cardiac failure*** - **Cardiac failure** leads to reduced cardiac output, causing blood to back up in the **pulmonary and systemic circulation**, resulting in fluid accumulation in the lungs (pulmonary edema), which manifests as **shortness of breath** [1]. - The heart's inability to pump efficiently results in increased hydrostatic pressure in capillaries, pushing fluid into interstitial spaces and pleural effusions, exacerbating respiratory distress [1]. *Nephritic syndrome* - **Nephritic syndrome** is characterized by inflammation of the glomeruli, leading to **hematuria, proteinuria, and hypertension**. While it can cause fluid retention due to impaired kidney function, it primarily presents with acute renal injury and less direct, rapid onset pulmonary edema compared to cardiac failure. - The fluid accumulation in **nephritic syndrome** is more generalized (edema) rather than acutely focused on pulmonary congestion leading to shortness of breath, as seen in heart failure. *TB* - **Tuberculosis (TB)** primarily affects the lungs, causing **inflammation, granuloma formation, and tissue destruction**, but usually does not directly cause acute fluid overload and pulmonary edema leading to shortness of breath in the manner that heart failure does. - While **TB** can cause pleural effusions, it is not typically associated with widespread fluid overload and acute pulmonary congestion as a primary mechanism of shortness of breath. *Portal hypertension* - **Portal hypertension** is an increase in blood pressure within the **portal venous system**, usually due to liver cirrhosis. This primarily leads to fluid accumulation in the **abdominal cavity (ascites)** and sometimes peripheral edema. - While significant ascites can indirectly limit diaphragmatic movement and cause some breathlessness, it does not directly cause the acute **pulmonary edema** and fluid overload that are hallmarks of cardiac failure presenting with severe shortness of breath.
Question 10: Which drug is used as an adjunct to epinephrine in refractory ventricular fibrillation/ventricular tachycardia during cardiac arrest?
- A. Atropine
- B. Adenosine
- C. High dose vasopressin
- D. Amiodarone infusion (Correct Answer)
Explanation: ***Amiodarone infusion*** - **Amiodarone** is a **Class III antiarrhythmic** drug commonly used in advanced cardiac life support (ACLS) protocols for refractory **ventricular fibrillation (VF)** or **pulseless ventricular tachycardia (VT)** that persists despite defibrillation and epinephrine [1]. - It works by blocking potassium channels, prolonging repolarization and the refractory period, which helps to stabilize the electrical activity of the heart. *Atropine* - **Atropine** is an anticholinergic drug primarily used to treat **symptomatic bradycardia** by increasing heart rate. - It is not indicated for the treatment of **ventricular fibrillation** or **ventricular tachycardia** during cardiac arrest. *High dose vasopressin* - **Vasopressin** was previously included in some ACLS algorithms as an alternative to epinephrine for **vasoconstrictive effects**, but recent guidelines do not support its routine use in cardiac arrest. - While it can cause **vasoconstriction**, there is no evidence that high-dose vasopressin improves outcomes in refractory VF/VT over epinephrine. *Adenosine* - **Adenosine** is an antiarrhythmic drug used to treat **supraventricular tachycardias (SVTs)** by transiently blocking the AV node. - It is not effective for **ventricular fibrillation** or **ventricular tachycardia** and can even be harmful in these rhythms.
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