Cardiology Practice Questions

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.

Q: A 24-year-old woman notices pain in her left arm, made worse with use. She also has fatigue, fever, night sweats, and arthralgias. On examination, there are no palpable lymph nodes, and the joints and muscle strength are normal. The left radial pulse is absent, and there is a bruit over the left subclavian and common carotid arteries. Preliminary laboratory investigations reveal an elevated ESR and mild anemia. Which of the following vascular findings is most likely to be found in her?

high pressure in the legs and low pressure in the arms. ***High pressure in the legs and low pressure in the arms*** - Takayasu arteritis causes **stenosis** of the **aorta** and its major branches, leading to reduced blood flow and *low pressure* in the affected upper extremities [1]. - The *legs* often maintain more normal blood pressure because their arterial supply is typically less severely affected or distal to the significant stenoses, leading to a *discrepancy* where leg pressure is relatively higher [1]. *Low pressure in the legs and high pressure in the arms* - This pattern is characteristic of **coarctation of the aorta** *distal to the subclavian artery*, where blood flow to the lower extremities is restricted, resulting in *lower leg pressure*. - Although Takayasu arteritis can affect any major vessel, the symptoms here (absent radial pulse, bruits in subclavian/carotid) indicate primary involvement of the *upper body vasculature*, with relatively preserved lower body perfusion [1]. *High-pitched diastolic murmur* - A high-pitched diastolic murmur is a common finding in **aortic regurgitation**, which is not directly indicated by the patient's symptoms of **pain in the arm**, **absent radial pulse**, and **bruits**. - While Takayasu arteritis *can* lead to aortic root dilatation and aortic regurgitation in later stages, the primary vascular findings described relate to *arterial stenosis* and *reduced pulse pressure* in the upper limbs, not valvular dysfunction [1]. *Normal blood pressure in both arms and legs* - This finding would contradict the patient's symptoms of **arm pain**, an **absent radial pulse**, and **arterial bruits**, all of which suggest significant vascular compromise [1]. - Normal blood pressure and pulses would rule out any major arterial stenosis or occlusion, which is central to the diagnosis of **Takayasu arteritis** [1].

Q: Radiofrequency ablation treatment is most useful in:

WPW syndrome. ***WPW syndrome*** - **Radiofrequency ablation** is highly effective in **Wolff-Parkinson-White (WPW) syndrome** by targeting and destroying the **accessory pathway** responsible for re-entry arrhythmias, thereby curing the condition [1]. - Patients with symptomatic WPW, especially those with **recurrent supraventricular tachycardias (SVTs)** or a high risk of sudden cardiac death, are excellent candidates for ablation. *Ventricular fibrillation* - **Ventricular fibrillation** is an immediate **life-threatening arrhythmia** requiring prompt **defibrillation** and often lacks a discrete, ablatable anatomical target that can be precisely modulated by radiofrequency ablation [2]. - It usually occurs in the setting of **structural heart disease** or acute **myocardial ischemia**, which are not directly treated by ablation. *Ventricular premature complex* - While radiofrequency ablation can be used for **highly symptomatic** and frequent **ventricular premature complexes (VPCs)**, it is generally considered after other medical therapies have failed, especially if structural heart disease is absent. - VPCs alone, without sustained arrhythmias or significant symptoms, are often managed **conservatively** or with antiarrhythmic medications rather than invasive ablation. *Atrial fibrillation* - **Atrial fibrillation** can be treated with radiofrequency ablation (pulmonary vein isolation), but it is generally performed for **symptomatic** and **refractory cases** after **antiarrhythmic drugs** have failed [1]. - The success rates can vary, and it is a more complex procedure compared to ablation for accessory pathways, often requiring repeat procedures.

Q: Eisenmenger complex is common in adult in –

VSD. ***VSD*** - A large, uncorrected **ventricular septal defect (VSD)** is the most common congenital heart defect to progress to **Eisenmenger syndrome** in adults. [1] - The bidirectional or right-to-left shunting through the VSD eventually leads to **pulmonary hypertension** and and systemic cyanosis. [1] *Cushion defect* - While **atrioventricular septal defects (AVSDs)**, or cushion defects, can lead to pulmonary hypertension, they are less common causes of Eisenmenger syndrome than VSDs in adults. [1] - They involve defects in both atrial and ventricular septa, often seen in individuals with **Down syndrome**. [1] *ASD* - **Atrial septal defects (ASDs)** typically involve left-to-right shunting, and while they can cause pulmonary hypertension over many decades, they rarely progress to full Eisenmenger syndrome due to the lower pressure differential between the atria. [1] - The elevated pulmonary pressures with ASD tend to be less severe and slower in onset compared to VSDs or PDAs. [1] *PDA* - A **patent ductus arteriosus (PDA)** can lead to Eisenmenger syndrome, but it is less common in adults than VSDs because PDAs are often recognized and closed earlier in life. [1] - An uncorrected large PDA results in chronic left-to-right shunting, leading to increased pulmonary blood flow and subsequent **pulmonary vascular disease**. [1]

Q: Cardiomyopathy is not a feature of

Lowe's syndrome. ***Lowe's syndrome*** - **Lowe's syndrome** (oculocerebrorenal syndrome) is characterized by congenital cataracts, intellectual disability, and renal tubulopathy, but **not cardiomyopathy**. - The primary cardiac manifestations in Lowe's syndrome are **mitral valve prolapse** and left ventricular hypertrophy, but not a progressive cardiomyopathy as a defining feature. *Duchenne's Muscular Dystrophy* - **Dilated cardiomyopathy** is a very common and significant feature of Duchenne's Muscular Dystrophy, often leading to heart failure [1], [2]. - Cardiac involvement is a major cause of morbidity and mortality in these patients, with **fibrosis** being a common finding [1]. *Friedreich's ataxia* - **Hypertrophic cardiomyopathy** is a prominent and frequent complication of Friedreich's ataxia, affecting a majority of patients. - It can lead to heart failure, arrhythmias, and is a major cause of death in affected individuals. *Pompe disease* - Infantile-onset Pompe disease is characterized by severe **hypertrophic cardiomyopathy** due to the accumulation of glycogen in cardiac muscle. - Cardiac involvement is often life-threatening and a hallmark of the severe forms of the disease.

Q: 25-year-old female presented to emergency with palpitations and dizziness. ECG was done and was diagnosed supraventricular tachycardia. Her blood pressure was 60/40 mm Hg. First line of management for this patient is ?

Cardioversion. ***Cardioversion*** - This patient presents with **supraventricular tachycardia (SVT)** and is **hemodynamically unstable** (blood pressure 60/40 mmHg), indicating the need for immediate intervention. - **Synchronized cardioversion** is the gold standard for unstable SVT as it rapidly restores sinus rhythm, preventing further deterioration. *Adenosine 12 mg IV* - While adenosine is a common treatment for stable SVT, the patient's **severe hypotension** makes it inappropriate as a first-line therapy. - Administering adenosine to an unstable patient could further worsen hypotension and lead to cardiac arrest. *Vagal manoeuvre* - **Vagal maneuvers** (e.g., Valsalva, carotid sinus massage) are effective first-line treatments for **stable SVT**. - However, they are **insufficient** for an unstable patient with profound hypotension, where rapid rhythm conversion is critical. *Adenosine 6 mg IV* - This is the **initial dose of adenosine** for stable SVT, but it is contraindicated in this hemodynamically unstable patient. - As with the 12 mg dose, adenosine can cause transient **heart block** and **hypotension**, which would be dangerous in an already hypotensive individual.

Q: Delta waves in ECG are characteristic of

Wolf Parkinson White syndrome. ***Wolf Parkinson White syndrome*** - A **delta wave** is a slurred upstroke at the beginning of the QRS complex, which is characteristic of **pre-excitation** in Wolf-Parkinson-White (WPW) syndrome [1]. - This occurs due to an **accessory pathway (Bundle of Kent)** that bypasses the AV node, leading to early ventricular activation [1]. *Bifascicular disease* - Refers to a conduction abnormality involving two fascicles of the **His-Purkinje system**, typically presenting as a combination of **right bundle branch block (RBBB)** with either left anterior or left posterior fascicular block. - ECG findings for bifascicular block do not include delta waves; instead, they show widened QRS complexes and axis deviations. *Trifascicular disease* - Involves conduction delay or block in all three fascicles of the **His-Purkinje system**, often manifest as alternating **bundle branch block patterns** or varying degrees of AV block. - It does not present with delta waves, but rather with **bradycardia** or episodes of syncope due to severe conduction disturbances. *RBBB* - **Right bundle branch block (RBBB)** is characterized by a widened QRS complex (>0.12s) with an **"M" pattern (RSR')** in leads V1-V3 and broad S waves in lateral leads (I, aVL, V5, V6). - RBBB indicates a delay in conduction through the right bundle branch, but it does not produce a delta wave, which is specific to pre-excitation.

Q: Lancisi's sign is seen in

TR. ***TR*** - **Lancisi's sign**, or a prominent **V wave in the jugular venous pulse**, is pathognomonic for **tricuspid regurgitation** [2]. - This sign indicates a rapid increase in **right atrial pressure** during ventricular systole due to backflow of blood from the right ventricle [2]. *AS* - **Aortic stenosis** typically presents with a **delayed and diminished carotid pulse** (pulsus parvus et tardus) and a **systolic ejection murmur**. - It does not involve abnormalities of the jugular venous pulse. *Aortic Regurgitation* - **Aortic regurgitation** is characterized by a **collapsing pulse** (Corrigan's pulse) and a **diastolic decrescendo murmur** [3]. - Jugular venous pulse abnormalities are not primary features of aortic regurgitation. *MS* - **Mitral stenosis** is associated with a **loud S1** sound and a **mid-diastolic murmur**, often with an opening snap [1]. - While it can cause pulmonary hypertension and subsequently right-sided heart failure leading to elevated JVP, it doesn't specifically cause a prominent V wave (Lancisi's sign).

Q: What is the mechanism of aortic regurgitation in a case of VSD?

Prolapse of right coronary leaflet. ***Prolapse of right coronary leaflet*** - In certain types of **ventricular septal defects (VSDs)**, particularly infracristal or supracristal defects, the lack of support for the **aortic valve cusps**, especially the right coronary leaflet, can lead to its **prolapse**. - This **prolapse** into the VSD creates an incomplete coaptation of the aortic valve leaflets, resulting in **aortic regurgitation**. *Congenital defect* - While VSD is a **congenital heart defect**, aortic regurgitation itself is not typically a direct, primary congenital defect associated with VSD. - Instead, the VSD indirectly *causes* the aortic regurgitation through secondary mechanisms such as leaflet prolapse or distortion. *Changes in the pressure gradient due to left to right shunt* - A left-to-right shunt causes increased pulmonary blood flow and can lead to **pulmonary hypertension**, but it does not directly explain the mechanism of **aortic valve insufficiency**. - While pressure changes are present, they do not cause the mechanical distortion or prolapse of the aortic valve leaflet that leads to regurgitation. *Eisenmengerization* - **Eisenmenger syndrome** is a late complication of large left-to-right shunts where pulmonary vascular disease leads to **reversal of the shunt (right-to-left)**. - This condition does not directly cause aortic regurgitation but rather primarily affects **pulmonary artery pressure** and flow dynamics.

Question 1

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 2

Investigation of choice for valvular heart disease-

Accepted Answer

2 D- Echocardiography

Answer

Nuclear Cardiac imaging

Answer

Precordial Doppler

Answer

MRI

Question 3

A 24-year-old woman notices pain in her left arm, made worse with use. She also has fatigue, fever, night sweats, and arthralgias. On examination, there are no palpable lymph nodes, and the joints and muscle strength are normal. The left radial pulse is absent, and there is a bruit over the left subclavian and common carotid arteries. Preliminary laboratory investigations reveal an elevated ESR and mild anemia. Which of the following vascular findings is most likely to be found in her?

Accepted Answer

high pressure in the legs and low pressure in the arms

Answer

low pressure in the legs and high pressure in the arms

Answer

high-pitched diastolic murmur

Answer

normal blood pressure in both arms and legs

Question 4

Radiofrequency ablation treatment is most useful in:

Accepted Answer

WPW syndrome

Answer

Ventricular fibrillation

Answer

Ventricular premature complex

Answer

Atrial fibrillation

Question 5

Eisenmenger complex is common in adult in –

Accepted Answer

VSD

Answer

Cushion defect

Answer

ASD

Answer

PDA

Question 6

Cardiomyopathy is not a feature of

Accepted Answer

Lowe's syndrome

Answer

Duchenne's Muscular Dystrophy

Answer

Friedreich's ataxia

Answer

Pompe disease

Question 7

25-year-old female presented to emergency with palpitations and dizziness. ECG was done and was diagnosed supraventricular tachycardia. Her blood pressure was 60/40 mm Hg. First line of management for this patient is ?

Accepted Answer

Cardioversion

Answer

Adenosine 12 mg IV

Answer

Vagal manoeuvre

Answer

Adenosine 6 mg IV

Question 8

Delta waves in ECG are characteristic of

Accepted Answer

Wolf Parkinson White syndrome

Answer

Bifascicular disease

Answer

Trifascicular disease

Answer

RBBB

Question 9

Lancisi's sign is seen in

Accepted Answer

TR

Answer

AS

Answer

Aortic Regurgitation

Answer

MS

Question 10

What is the mechanism of aortic regurgitation in a case of VSD?

Accepted Answer

Prolapse of right coronary leaflet

Answer

Congenital defect

Answer

Changes in the pressure gradient due to left to right shunt

Answer

Eisenmengerization

Cardiology — MCQs

Cardiology — MCQs

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