Cardiology Practice Questions

Q: Which valve is least affected in Rheumatic fever ?

Pulmonary valve. ***Pulmonary valve*** - The **pulmonary valve** is considered the **least commonly affected** heart valve in rheumatic fever. - This is thought to be due to the relatively lower pressure on the right side of the heart, making it less susceptible to inflammatory damage. *Aortic valve* - The **aortic valve** is the **second most commonly affected** valve in rheumatic fever, often leading to **aortic stenosis** or regurgitation [1]. - Inflammation can cause thickening, calcification, and fusion of the leaflets. *Mitral valve* - The **mitral valve** is the **most frequently affected** heart valve in rheumatic fever, almost always involved to some degree [1]. - Chronic inflammation typically leads to **mitral stenosis**, but regurgitation can also occur. *Tricuspid valve* - The **tricuspid valve** is affected in a significant number of cases, though less often than the mitral and aortic valves [2]. - When involved, it typically presents as **tricuspid regurgitation** due to leaflet damage and annular dilation [2].

Q: Balloon valvotomy is successful in all of the following cases except –

Calcified mitral stenosis. ***Calcified mitral stenosis*** - **Heavily calcified valves** are generally considered a contraindication for balloon valvotomy due to the high risk of **valve tearing**, embolism, and suboptimal results. - The rigid, non-compliant nature of heavily calcified valves prevents effective leaflet separation, reducing the chances of a successful procedure and increasing the risk of adverse events. *Congenital pulmonary stenosis* - **Balloon pulmonary valvotomy** is the treatment of choice for most cases of symptomatic congenital pulmonary stenosis with a significant gradient. - It effectively dilates the stenotic valve, leading to a good prognosis and long-term results. *Congenital aortic stenosis* - **Balloon aortic valvotomy** is often performed for severe congenital aortic stenosis, especially in infants and young children, to relieve obstruction. - While it can be associated with some risk of aortic regurgitation, it is a viable option to improve hemodynamics. *Mitral stenosis in pregnancy* - **Balloon mitral valvotomy** is a safe and effective treatment for symptomatic severe mitral stenosis during pregnancy, especially if medical management fails. - It can significantly improve maternal and fetal outcomes by reducing pulmonary congestion and improving cardiac output.

Q: What is the MOST common radiographic manifestation of acute papillary muscle rupture?

Pulmonary edema. ***Pulmonary edema*** - Acute **papillary muscle rupture** leads to severe **mitral regurgitation**, causing a sudden increase in left atrial pressure. - This rapid rise in pressure is directly transmitted to the **pulmonary veins and capillaries**, resulting in the extravasation of fluid into the lungs, manifesting as **pulmonary edema** on chest X-ray. - This is the **most common radiographic finding** because the acute nature of the rupture causes immediate hemodynamic consequences affecting the pulmonary circulation. *Left atrial enlargement* - **Left atrial enlargement** typically develops over time in chronic mitral regurgitation due to sustained volume overload. - In acute papillary muscle rupture, the onset of mitral regurgitation is sudden, and there isn't sufficient time for the left atrium to undergo **significant remodeling and enlargement**. *Left ventricular enlargement* - **Left ventricular enlargement** is also a feature of chronic volume overload (e.g., chronic mitral regurgitation or aortic regurgitation). - Acute papillary muscle rupture causes sudden pressure overload on the left atrium and pulmonary circulation, and the **left ventricle has not yet had time to dilate** in response to the acute insult. *Pericardial effusion* - **Pericardial effusion** is an accumulation of fluid in the pericardial sac and is not a direct consequence of papillary muscle rupture. - While other cardiac pathologies like **myocardial infarction** (which can cause papillary muscle rupture) can sometimes be complicated by a small pericardial effusion, it is not the most common or direct radiographic manifestation of the rupture itself.

Q: Which of the following defines Pentalogy of Fallot?

TOF with ASD. ***TOF with ASD*** - **Pentalogy of Fallot** is a rare congenital heart defect that includes the **four classic defects of Tetralogy of Fallot (TOF)** plus an **atrial septal defect (ASD)**. - The four defects in TOF are **ventricular septal defect (VSD)**, **pulmonary stenosis**, **right ventricular hypertrophy**, and **overriding aorta** [1]. *TOF with Polysplenia* - **Polysplenia** is a developmental anomaly characterized by multiple small spleens, often associated with other complex congenital abnormalities, but not a defining feature of Pentalogy of Fallot. - While it can occur with congenital heart defects, it's not one of the five specific components that define the pentalogy. *TOF with COA* - **Coarctation of the aorta (COA)** is a narrowing of the aorta, often seen with other congenital heart defects but is not part of the defining criteria for Pentalogy of Fallot. - It involves a separate anatomical abnormality that is not included in the "pentalogy." *TOF with PDA* - A **patent ductus arteriosus (PDA)** is a persistence of the fetal connection between the aorta and pulmonary artery. While it can coexist with TOF, it is not one of the defining features of Pentalogy of Fallot. - The fifth defect defining the pentalogy is specifically an **atrial septal defect (ASD)**, not a PDA.

Q: Differential cyanosis is seen in –

PDA. ***PDA*** - **Differential cyanosis** occurs in **patent ductus arteriosus (PDA)** with severe **pulmonary hypertension** leading to **right-to-left shunting** (reversed PDA/Eisenmenger syndrome). - Since the PDA connects the pulmonary artery to the descending aorta **below the origin of the left subclavian artery**, deoxygenated blood from the pulmonary artery perfuses the **lower body** (lower limbs cyanosed) while the **upper body** receives oxygenated blood from the left ventricle (upper limbs and head pink). - This creates the classic pattern: **pink upper extremities, cyanosed lower extremities**. *VSD* - A **ventricular septal defect (VSD)** typically causes **left-to-right shunting**, leading to increased pulmonary blood flow, and does not result in differential cyanosis. - While VSD can eventually lead to **Eisenmenger syndrome** with **generalized cyanosis** (affecting entire body uniformly), it does not specifically cause differential cyanosis because the shunt occurs before blood reaches the systemic circulation. *TAPVC* - **Total anomalous pulmonary venous connection (TAPVC)** is a congenital heart defect where all pulmonary veins drain into the systemic venous circulation, leading to **generalized cyanosis** as mixed blood is delivered throughout the body. - It does not present with differential cyanosis, as the venous return is uniformly deoxygenated and mixes before systemic distribution. *TGV* - **Transposition of the great vessels (TGV)** involves the aorta originating from the right ventricle and the pulmonary artery from the left ventricle, creating two parallel circulations. - This condition presents with **severe generalized cyanosis** shortly after birth unless there is mixing between the two circulations (via PDA, ASD, or VSD), and does not cause differential cyanosis.

Q: A “Potential Anastomosis” seen in

Coronary artery. A “Potential Anastomosis” seen in ***Coronary artery*** - Coronary arteries are classic examples of **functional end arteries** that have potential anastomoses, meaning these connections are normally non-functional but can become patent in cases of **ischemia**, such as occurs with a gradual occlusion [1]. - While small collateral vessels exist, they are usually insufficient to prevent myocardial damage if a major coronary artery is suddenly occluded. *Intercostal artery* - Intercostal arteries form extensive **anastomoses** with each other and with branches of the internal thoracic and musculophrenic arteries, providing a rich collateral circulation. - They are typically considered true end arteries but their abundant connections allow them to maintain tissue perfusion even if one segment is blocked. *Arterial arcades of mesentery* - The arterial arcades in the mesentery, formed by the **jejunal and ileal arteries**, are extensive and provide excellent collateral circulation to the small intestine. - This robust network ensures that obstruction of a single mesenteric artery often does not lead to **ischemia** of the corresponding bowel segment. *Labial branch of facial artery* - The labial branches of the facial artery extensively **anastomose** with corresponding branches from the opposite side and with branches of the infraorbital and mental arteries. - This rich network provides a robust blood supply to the lips and perioral region, making this a region with **true anastomoses** rather than just potential ones.

Q: Most common type of atrial septal defect is ___________

Ostium secondum. ***Ostium secondum*** - This is the **most common type of atrial septal defect (ASD)**, accounting for about **70% of all ASDs** [1]. - It results from an insufficient growth of the **septum secundum** or excessive resorption of the septum primum, causing an opening in the region of the **fossa ovalis** [1]. *Ostium primum* - This type of ASD is less common, making up about **15-20% of all ASDs**. - It is typically associated with other **endocardial cushion defects** [2], such as a cleft in the anterior leaflet of the **mitral valve**. *Endocardial cushion defect* - This is a broader category of congenital heart defects that includes **ostium primum ASDs**, ventricular septal defects, and common atrioventricular canals. - While an ostium primum ASD is an endocardial cushion defect, it is not the most common *type* of ASD overall. *Endocardial hypertrophy* - **Endocardial hypertrophy** refers to the thickening of the endocardium, which is the inner lining of the heart. - This is a **pathological response** to conditions like increased pressure or volume overload, and it is **not a type of atrial septal defect**.

Q: Which of the following is a new major Jones criterion in a high-risk population, according to the AHA & World Health Federation 2015 criteria?

Monoarthritis. ***Monoarthritis*** - In a **high-risk population**, the 2015 AHA guidelines for diagnosing **acute rheumatic fever** (ARF) include monoarthritis as a **major criterion**. [1] - This update acknowledges that in populations with a high burden of ARF, even a single joint involvement can be indicative of the disease. *Polyarthritis* - **Polyarthritis** has traditionally been a major Jones criterion and remains so; however, the question specifically asks for a *new* major criterion in high-risk populations. [1] - While relevant, it is not the specific *new* update for high-risk populations as monoarthritis is. *Monoarthralgia* - **Monoarthralgia** is considered a **minor criterion** in both low-risk and high-risk populations because it represents joint pain without inflammatory signs or objective findings. - Minor criteria alone are insufficient for diagnosing ARF without major criteria or evidence of preceding streptococcal infection. [1] *Chorea* - **Sydenham chorea** is a well-established **major Jones criterion** for ARF, recognized for its characteristic involuntary movements. [1] - It is not a *newly* added major criterion but rather a classical manifestation of ARF.

Q: All are signs of impending Eisenmenger except –

Increased flow murmur across tricuspid & pulmonary valve. Increased flow murmur across tricuspid & pulmonary valve [1] - As pulmonary hypertension develops and the shunt reverses (right-to-left), flow across the tricuspid and pulmonary valves typically **decreases**, not increases. - Therefore, an increased flow murmur would be an atypical finding and would not signify impending Eisenmenger syndrome. *Single S2* - A single S2 is observed because **pulmonary hypertension** causes the P2 component to become loud and occur earlier, merging with the A2 sound. - This signifies increased pulmonary vascular resistance, an essential step towards Eisenmenger syndrome. *Graham steel murmur* - The Graham Steell murmur is a **diastolic murmur** indicative of **pulmonary regurgitation** secondary to severe pulmonary hypertension. - This murmur can develop as pulmonary artery pressures rise significantly, leading to Eisenmenger syndrome. *Loud P2* - A prominent or **loud P2** (pulmonary component of the second heart sound) is a direct consequence of elevated pulmonary artery pressure [1]. - This is a critical sign of developing pulmonary hypertension, reflecting the increased resistance in the pulmonary vasculature.

Q: Investigation of choice for valvular heart disease-

2 D- Echocardiography. ***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 1

Which valve is least affected in Rheumatic fever ?

Accepted Answer

Pulmonary valve

Answer

Aortic valve

Answer

Mitral valve

Answer

Tricuspid valve

Question 2

Balloon valvotomy is successful in all of the following cases except –

Accepted Answer

Calcified mitral stenosis

Answer

Congenital pulmonary stenosis

Answer

Congenital aortic stenosis

Answer

Mitral stenosis in pregnancy

Question 3

What is the MOST common radiographic manifestation of acute papillary muscle rupture?

Accepted Answer

Pulmonary edema

Answer

Left atrial enlargement

Answer

Left ventricular enlargement

Answer

Pericardial effusion

Question 4

Which of the following defines Pentalogy of Fallot?

Accepted Answer

TOF with ASD

Answer

TOF with Polysplenia

Answer

TOF with COA

Answer

TOF with PDA

Question 5

Differential cyanosis is seen in –

Accepted Answer

PDA

Answer

VSD

Answer

TAPVC

Answer

TGV

Question 6

A “Potential Anastomosis” seen in

Accepted Answer

Coronary artery

Answer

Intercostal artery

Answer

Arterial arcades of mesentery

Answer

Labial branch of facial artery

Question 7

Most common type of atrial septal defect is ___________

Accepted Answer

Ostium secondum

Answer

Ostium primum

Answer

Endocardial cushion defect

Answer

Endocardial hypertrophy

Question 8

Which of the following is a new major Jones criterion in a high-risk population, according to the AHA & World Health Federation 2015 criteria?

Accepted Answer

Monoarthritis

Answer

Polyarthritis

Answer

Monoarthralgia

Answer

Chorea

Question 9

All are signs of impending Eisenmenger except –

Accepted Answer

Increased flow murmur across tricuspid & pulmonary valve

Answer

Single S2

Answer

Graham steel murmur

Answer

Loud P2

Question 10

Investigation of choice for valvular heart disease-

Accepted Answer

2 D- Echocardiography

Answer

Nuclear Cardiac imaging

Answer

Precordial Doppler

Answer

MRI

Cardiology — MCQs

Cardiology — MCQs

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