Cardiology Practice Questions

Q: A patient in regular rhythm presents with absent P waves on ECG. Leads II, III and aVF reveal a saw-tooth pattern. Which of the following is the most likely diagnosis?

Atrial Flutter with Fixed Block. The presence of a **"saw-tooth" pattern** in the inferior leads (II, III, and aVF) is the pathognomonic ECG finding for **Atrial Flutter** [2]. This pattern represents "F-waves" (flutter waves) caused by a macro-reentrant circuit, typically around the tricuspid valve annulus [2]. The question specifies that the patient is in a **regular rhythm**. In Atrial Flutter, the AV node usually acts as a gatekeeper, allowing only every 2nd, 3rd, or 4th atrial impulse to pass (e.g., 2:1, 3:1, or 4:1 conduction). When this ratio remains constant, it is termed a **Fixed Block**, resulting in a perfectly regular ventricular rate. **Why other options are incorrect:** * **Atrial Fibrillation:** Characterized by an "irregularly irregular" rhythm and the absence of organized P waves or saw-tooth patterns; instead, it shows fine fibrillatory waves [1]. * **Atrial Flutter with Variable Block:** While it shows saw-tooth waves, the changing conduction ratio (e.g., switching between 2:1 and 3:1) would result in an **irregular** rhythm. * **Multifocal Atrial Tachycardia (MAT):** Characterized by at least three different P-wave morphologies and irregular RR intervals, typically seen in COPD patients. **High-Yield Clinical Pearls for NEET-PG:** * **Atrial Rate:** In flutter, the atrial rate is typically **250–350 bpm** [2]. * **Common Presentation:** A narrow QRS tachycardia with a regular heart rate of exactly **150 bpm** is Atrial Flutter with 2:1 block until proven otherwise. * **Treatment of Choice:** For long-term management, **Radiofrequency Ablation** of the cavotricuspid isthmus (CTI) is the definitive treatment with a high success rate [1]. * **Carotid Sinus Massage:** This maneuver increases the AV block, making the underlying saw-tooth waves more visible on ECG, aiding diagnosis.

Q: Intracavitary electrocardiography is a diagnostic aid in which of the following conditions?

Ebstein's anomaly of the tricuspid valve. The provided explanation describes Ebstein’s anomaly and its pathognomonic diagnostic findings. However, after evaluating the available references, none of the provided sources [1-5] contain information regarding Ebstein’s anomaly, intracavitary electrocardiography, or the specific physiological dissociation (atrial pressure with ventricular ECG) described in the explanation. The references focus broadly on general ECG axis, Holter monitoring, and heart murmurs, without mentioning the diagnostic aid in question.

Q: All of the following are true about right ventricular infarct EXCEPT:

Normal JVP. **Explanation:** Right Ventricular (RV) Infarction typically occurs in the setting of an acute inferior wall myocardial infarction (involving the Right Coronary Artery). The pathophysiology centers on **RV pump failure**, leading to a backup of pressure into the systemic venous circulation [1]. **1. Why "Normal JVP" is the correct answer (The Exception):** In RV infarction, the right ventricle cannot effectively pump blood into the pulmonary circulation. This leads to an immediate increase in right atrial pressure, which is clinically manifested as **elevated Jugular Venous Pressure (JVP)**. A normal JVP is virtually never seen in a hemodynamically significant RV infarct; in fact, the presence of distended neck veins in a patient with hypotension and clear lungs is the classic diagnostic triad (Saunders' Triad). **2. Analysis of other options:** * **Nocturia:** Venous congestion leads to the accumulation of interstitial fluid in the lower extremities during the day. At night, when the patient lies supine, this fluid is redistributed and filtered by the kidneys, causing nocturia. * **Hepatomegaly & Ascites:** These are classic signs of systemic venous congestion. Chronic or subacute right-sided heart failure leads to "congestive hepatopathy" (nutmeg liver) and the transudation of fluid into the peritoneal cavity (ascites) [2]. **Clinical Pearls for NEET-PG:** * **Triad of RV Infarct:** Hypotension, Elevated JVP, and **Clear Lungs** (absence of pulmonary edema). * **Kussmaul’s Sign:** An inspiratory rise in JVP (often positive in RV infarct). * **Diagnosis:** ST-elevation in **V4R** (right-sided chest lead) is the most sensitive marker. * **Management:** Avoid nitrates/diuretics (which decrease preload); the mainstay of treatment is **aggressive IV fluids** to maintain RV filling pressure.

Q: A 75-year-old man presents with a syncopal episode. He had no incontinence or post-event confusion. Examination reveals a blood pressure of 140/80 mm Hg, pulse of 72/min with no postural changes. His second heart sound is diminished, and there is a systolic ejection murmur that radiates to the carotids. The Valsalva maneuver decreases the murmur's length and intensity. What is the most likely diagnosis for this patient's systolic murmur?

aortic stenosis. **Explanation:** The clinical presentation of **syncope**, a **diminished second heart sound (S2)**, and a **systolic ejection murmur radiating to the carotids** [1] is classic for **Aortic Stenosis (AS)**. In elderly patients, AS is most commonly due to senile calcification [2]. **Why Aortic Stenosis is correct:** * **Murmur Characteristics:** It is a crescendo-decrescendo systolic murmur heard best at the right second intercostal space. Radiation to the carotids (carotid shudder) is a hallmark [1]. * **S2 Changes:** As the valve becomes more calcified and immobile, the aortic component of the second heart sound (A2) decreases in intensity [1]. * **Valsalva Maneuver:** This maneuver decreases venous return (preload). In AS, reduced preload leads to less blood flowing across the stenotic valve [3], thereby **decreasing** the murmur's intensity. **Why other options are incorrect:** * **HOCM:** While HOCM also presents with a systolic ejection murmur and syncope, the murmur **increases** in intensity with Valsalva (due to decreased LV volume increasing outflow obstruction) [3]. It typically does not radiate to the carotids. * **Mitral Regurgitation (MR):** MR presents with a **holosystolic** (pansystolic) murmur heard best at the apex radiating to the axilla, not an ejection murmur radiating to the carotids. * **Tricuspid Regurgitation (TR):** TR is a holosystolic murmur heard at the left lower sternal border that **increases with inspiration** (Carvallo's sign). **NEET-PG High-Yield Pearls:** * **SAD Triad of AS:** **S**yncope, **A**ngina, and **D**yspnea (indicates heart failure). * **Pulsus Parvus et Tardus:** A small-amplitude, delayed carotid pulse is a classic sign of severe AS. * **Dynamic Auscultation:** Most murmurs decrease with Valsalva/Standing (decreased preload) **EXCEPT** HOCM and Mitral Valve Prolapse (MVP), which increase [3].

Q: Cardiomyopathy may be seen in all of the following conditions except?

Alkaptonuria. **Explanation:** The correct answer is **Alkaptonuria**. This question tests your ability to differentiate between systemic diseases that involve the myocardium (causing cardiomyopathy) and those that primarily affect the valvular or vascular structures. **1. Why Alkaptonuria is the correct answer:** Alkaptonuria is an autosomal recessive disorder caused by a deficiency of **homogentisate 1,2-dioxygenase**, leading to the accumulation of homogentisic acid. While it has significant cardiovascular manifestations due to pigment deposition (ochronosis), it typically causes **valvular heart disease** (most commonly aortic stenosis) and **coronary artery disease** (due to accelerated atherosclerosis). It does not typically result in primary cardiomyopathy. **2. Why the other options are incorrect:** * **Duchenne Muscular Dystrophy (DMD):** Dystrophin is present in both skeletal and cardiac muscle. Its absence leads to progressive fibrosis of the myocardium, typically resulting in **Dilated Cardiomyopathy (DCM)** [1]. * **Friedreich's Ataxia:** This is the most common inherited ataxia. Up to 90% of patients develop cardiac involvement, most characteristically **Hypertrophic Cardiomyopathy (HCM)**, which can eventually progress to heart failure [2]. * **Type II Glycogen Storage Disease (Pompe Disease):** This is a lysosomal storage disorder (acid maltase deficiency). It is a classic cause of **massive cardiomegaly** and hypertrophic cardiomyopathy in infants due to excessive glycogen deposition in cardiac myocytes. **Clinical Pearls for NEET-PG:** * **Pompe Disease:** Look for "massive cardiomegaly" and "short PR interval" on ECG in an infant. * **Friedreich's Ataxia:** The most common cause of death is heart failure/arrhythmia due to cardiomyopathy. * **Alkaptonuria Triad:** Ochronotic arthritis, dark urine (on standing), and black pigmentation of the sclera/ear cartilage. Remember: **Valves, not Myocardium.**

Q: All of the following are electrocardiographic features of hyperkalemia, except?

Prolonged QT interval. **Explanation:** Hyperkalemia is a critical electrolyte abnormality that alters the resting membrane potential of myocytes, leading to predictable sequential changes on an ECG [1]. **Why Prolonged QT Interval is the Correct Answer:** Hyperkalemia typically causes **shortening of the QT interval**, not prolongation. This occurs because high extracellular potassium levels increase the speed of repolarization (Phase 3 of the action potential), leading to narrow, peaked T waves and a shortened QT duration. In contrast, **Hypokalemia** is associated with QT prolongation (often due to prominent U waves). **Analysis of Incorrect Options:** * **Prolonged PR interval:** As potassium levels rise (typically >6.5 mEq/L), conduction through the atria and AV node slows down, leading to PR interval prolongation. * **Loss of P waves:** As toxicity progresses, the P wave flattens and eventually disappears (Atrial standstill) because the atrial myocardium becomes inexcitable [1]. * **Sine wave patterns:** This is a late, pre-terminal sign of severe hyperkalemia (>8.0 mEq/L). The QRS complex widens significantly and merges with the T wave, creating a characteristic sinusoidal appearance, which can rapidly degenerate into ventricular fibrillation or asystole [1]. **High-Yield NEET-PG Pearls:** * **Earliest sign:** Tall, "tented" or peaked T waves (best seen in V2-V4) [1]. * **Sequence of changes:** Peaked T waves → PR prolongation/P wave flattening → QRS widening → Sine wave → Asystole [1]. * **Treatment:** Calcium gluconate (stabilizes the cardiac membrane) is the first step if ECG changes are present [2], followed by insulin/dextrose and salbutamol to shift K+ intracellularly.

Q: A 50-year-old man with aortic stenosis is exercising for 11 minutes according to the Bruce protocol. Exercise is stopped due to fatigue. The regional pressure gradient between the two sides of the aortic valve is 60 mm Hg. What is the best management?

Observation. **Explanation:** The management of Aortic Stenosis (AS) is primarily guided by the presence of symptoms and the severity of the stenosis. In this scenario, the patient is **asymptomatic** (fatigue at 11 minutes of the Bruce protocol is a normal physiological response, not an exercise-induced symptom) and has a pressure gradient of 60 mmHg, which classifies as **Severe AS** (Mean gradient >40 mmHg) [1]. **Why Observation is correct:** Current guidelines (ACC/AHA) state that for asymptomatic patients with severe AS and preserved Left Ventricular Ejection Fraction (LVEF), the management is **watchful waiting** (Observation). Exercise testing is used to unmask "latent" symptoms [1]. Since this patient completed 11 minutes (Stage IV of Bruce protocol) and only stopped due to general fatigue—not chest pain, dyspnea, or hypotension—the test is considered negative for symptoms. Therefore, surgery is not yet indicated. **Why other options are incorrect:** * **Aortic Valve Replacement (B):** This is the definitive treatment but is reserved for *symptomatic* severe AS, asymptomatic severe AS with LVEF <50%, or those undergoing other cardiac surgeries. * **Angiogram (A):** Usually performed as a preoperative workup before valve surgery to check coronary anatomy; it is not indicated in an asymptomatic patient being managed conservatively. * **Aortic Ballooning (C):** Balloon Valvotomy is generally a palliative measure or a "bridge to surgery" in unstable patients or children; it is not a standard preventive treatment for stable adults [1]. **Clinical Pearls for NEET-PG:** * **Classic Triad of AS:** Dyspnea (most common), Angina, and Syncope (**SAD**). * **Severe AS Criteria:** Valve Area 40 mmHg, or Jet Velocity >4 m/s. * **Indication for Surgery in Asymptomatic AS:** LVEF 5 m/s).

Question 1

A patient in regular rhythm presents with absent P waves on ECG. Leads II, III and aVF reveal a saw-tooth pattern. Which of the following is the most likely diagnosis?

Accepted Answer

Atrial Flutter with Fixed Block

Answer

Atrial Fibrillation

Answer

Atrial Flutter with Variable Block

Answer

Multifocal Atrial Tachycardia

Question 2

Intracavitary electrocardiography is a diagnostic aid in which of the following conditions?

Accepted Answer

Ebstein's anomaly of the tricuspid valve

Answer

Tricuspid regurgitation

Answer

Endocardial fibroelastosis

Answer

Endomyocardial fibrosis

Question 3

All of the following are true about right ventricular infarct EXCEPT:

Accepted Answer

Normal JVP

Answer

Nocturia

Answer

Hepatomegaly

Answer

Ascites

Question 4

Infective endocarditis is common in which of the following conditions?

Accepted Answer

Mitral stenosis

Answer

Mitral regurgitation

Answer

Coarctation of aorta

Answer

Aortic regurgitation

Question 5

What is the commonest congenital lesion complicated by infective endocarditis?

Accepted Answer

Ventricular Septal Defect (VSD)

Answer

Atrial Septal Defect (ASD)

Answer

Patent Ductus Arteriosus (PDA)

Answer

Tetralogy of Fallot (TOF)

Question 6

A 75-year-old man presents with a syncopal episode. He had no incontinence or post-event confusion. Examination reveals a blood pressure of 140/80 mm Hg, pulse of 72/min with no postural changes. His second heart sound is diminished, and there is a systolic ejection murmur that radiates to the carotids. The Valsalva maneuver decreases the murmur's length and intensity. What is the most likely diagnosis for this patient's systolic murmur?

Accepted Answer

aortic stenosis

Answer

hypertrophic obstructive cardiomyopathy (HOCM)

Answer

mitral regurgitation (chronic)

Answer

tricuspid regurgitation

Question 7

Cardiomyopathy may be seen in all of the following conditions except?

Accepted Answer

Alkaptonuria

Answer

Duchene muscular dystrophy

Answer

Friedreich's ataxia

Answer

Type II glycogen storage disease

Question 8

A 64-year-old male presents with dyspnea and edema. He had previous coronary bypass surgery 5 years ago, which was uncomplicated. Since then he has had no further chest pain. On examination, his JVP is at 8 cm, with prominent Kussmaul's sign. The heart sounds are easily heard but there is an early diastolic filling sound (pericardial knock). For this patient, select the most likely diagnosis.

Accepted Answer

Constrictive pericarditis

Answer

Cardiac tamponade

Answer

Restrictive cardiomyopathy

Answer

Right ventricle myocardial infarction

Question 9

All of the following are electrocardiographic features of hyperkalemia, except?

Accepted Answer

Prolonged QT interval

Answer

Prolonged PR interval

Answer

Sine wave patterns

Answer

Loss of P waves

Question 10

A 50-year-old man with aortic stenosis is exercising for 11 minutes according to the Bruce protocol. Exercise is stopped due to fatigue. The regional pressure gradient between the two sides of the aortic valve is 60 mm Hg. What is the best management?

Accepted Answer

Observation

Answer

Angiogram

Answer

Aortic valve replacement

Answer

Aortic ballooning to prevent further derangement

Cardiology — MCQs

Cardiology — MCQs

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