Cardiology Practice Questions

Q: A person was brought to emergency department and was diagnosed with Supra ventricular tachycardia and suddenly he became unstable. What is the next line of management?

DC Cardioversion. ***DC Cardioversion*** - For **unstable supraventricular tachycardia (SVT)**, immediate **direct current (DC) cardioversion** is the definitive treatment to restore sinus rhythm. - Instability in SVT includes symptoms like hypotension, altered mental status, signs of shock, ischemic chest discomfort, or acute heart failure. *Intravenous ibutilide* - **Ibutilide** is an antiarrhythmic drug used for pharmacological cardioversion of recent-onset atrial fibrillation or flutter, but not typically for unstable SVT. - While it can convert certain supraventricular arrhythmias, it is generally reserved for **stable patients** and takes longer to act than immediate electrical cardioversion. *Intravenous Diltiazem* - **Diltiazem** is a calcium channel blocker used to control ventricular rate in **stable SVT**, atrial fibrillation, or flutter [1]. - It is contraindicated in unstable patients as it can further depress cardiac contractility and worsen hypotension [2]. *Intravenous Flecainide* - **Flecainide** is a class Ic antiarrhythmic drug used to maintain sinus rhythm in patients with supraventricular arrhythmias, including SVT. - It also takes time to act and is used in **stable patients** without structural heart disease, not in emergency unstable situations where immediate rhythm conversion is required.

Q: Which disease does not cause AV nodal block?

Cat scratch. ### Cat scratch - While cat scratch disease (caused by *Bartonella henselae*) can cause **lymphadenopathy** and other systemic symptoms, it is not typically associated with **AV nodal block** or direct cardiac involvement [1]. - The disease is usually self-limiting and rarely affects the electrical conduction system of the heart. ### Toxoplasmosis - **Toxoplasmosis**, caused by *Toxoplasma gondii*, can lead to **myocarditis** and **pericarditis**, which may disrupt the heart's electrical activity and cause AV nodal blocks, especially in immunocompromised individuals. - The parasite can directly infect cardiac muscle cells, leading to inflammation and conduction abnormalities. ### Chagas - **Chagas disease**, caused by *Trypanosoma cruzi*, is well-known for its propensity to cause **chronic Chagasic cardiomyopathy**, which frequently includes **AV nodal block** and other conduction defects [2]. - The parasite directly invades cardiac tissue, leading to fibrosis and destruction of the conduction system [2]. ### Lyme disease - **Lyme carditis**, a manifestation of Lyme disease caused by *Borrelia burgdorferi*, is a common cause of **AV nodal block**, often presenting with varying degrees of block. - The spirochete can directly infect the heart muscle, leading to inflammation and disruption of electrical pathways.

Q: A man who is chronic alcoholic will develop which type of cardiomyopathy?

Dilated cardiomyopathy. ***Dilated cardiomyopathy*** - Chronic alcohol abuse is a major cause of **dilated cardiomyopathy**, where the heart's pumping chambers (ventricles) become enlarged and weakened, leading to reduced cardiac output [1]. - This condition often called **alcoholic cardiomyopathy**, is characterized by **ventricular dilation** and **systolic dysfunction**. *Hypertrophic cardiomyopathy* - This condition involves thickening of the heart muscle, often genetic, and is not directly caused by **chronic alcoholism**. - While alcohol can worsen pre-existing heart conditions, it does not typically lead to primary **hypertrophic cardiomyopathy**. *Myocarditis* - **Myocarditis** is an inflammation of the heart muscle, usually caused by viral infections or autoimmune processes. - Although heavy alcohol use can weaken the immune system, it is not a direct cause of viral or primary inflammatory myocarditis. *Pericarditis* - **Pericarditis** is the inflammation of the pericardium, the sac surrounding the heart, most commonly due to viral infections or autoimmune conditions. - While alcohol abuse can have various systemic effects, it is not a recognized direct cause of **pericarditis**.

Q: Pulmonary Plethora is seen in -

TAPVC. ***TAPVC*** - **Total Anomalous Pulmonary Venous Connection (TAPVC)** leads to all pulmonary veins draining into the systemic circulation, causing a left-to-right shunt at the atrial level back into the right atrium. - This persistent shunting results in increased blood flow to the lungs, manifesting as **pulmonary plethora** on chest X-ray due to engorged pulmonary vessels [3]. *Tricuspid Atresia* - **Tricuspid atresia** results in an absence of the tricuspid valve, severely limiting blood flow from the right atrium to the right ventricle. - This condition typically leads to **pulmonary oligemia** (reduced blood flow to the lungs), not pulmonary plethora. *CoA* - **Coarctation of the aorta (CoA)** is a narrowing of the aorta, typically distal to the left subclavian artery [2]. - While it can lead to complications like heart failure, it generally does not directly cause **pulmonary plethora** unless there are associated shunts. *TOF* - **Tetralogy of Fallot (TOF)** is characterized by four defects: ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy [1]. - The most significant hemodynamic feature is **pulmonary stenosis**, which reduces blood flow to the lungs, leading to **pulmonary oligemia**, often described as a "boot-shaped" heart on X-ray [1].

Q: A 25-year-old female presented to ER unconscious. Her mother tells you about her having recurrent syncopal episodes. Her BP is 80/60 mm Hg and you order an ECG. Treatment is

DC shock. ***DC shock*** - The ECG shows a **wide complex tachycardia** with alternating morphology in the QRS complex, consistent with **Torsades de Pointes**. - Given the patient's **unconsciousness** and **hypotension (80/60 mmHg)**, she is hemodynamically unstable, making immediate **electrical cardioversion (DC shock)** the treatment of choice irrespective of the cause. *Catheter Ablation* - **Catheter ablation** is an invasive procedure used for definitive treatment of recurrent arrhythmias, often considered in patients who are *hemodynamically stable*. - It is not an acute, emergency treatment for an **unstable patient** in a life-threatening arrhythmia. *Adenosine* - **Adenosine** is primarily used to terminate **supraventricular tachycardias (SVTs)** and can be harmful in wide complex tachycardias, especially if due to ventricular tachycardia or Wolff-Parkinson-White syndrome. - Its use is contraindicated in wide complex tachycardias like Torsades de Pointes, and it would not be effective in an **unstable patient** with Torsades de Pointes. *Radiofrequency ablation* - **Radiofrequency ablation** is a type of catheter ablation, which ablates or destroys abnormal electrical pathways in the heart. - Similar to other ablative therapies, it is a **definitive treatment** for recurrent arrhythmias in *stable patients*, not an emergency measure for an unconscious, hypotensive patient with an acute arrhythmia.

Q: Stunning of myocardium without any acute coronary syndrome is:-

Takotsubo cardiomyopathy. ***Takotsubo cardiomyopathy*** - This condition involves **transient systolic dysfunction** of the left ventricle, often triggered by severe emotional or physical stress, mimicking a heart attack but without **coronary artery obstruction**. - The apical and mid-ventricular segments of the left ventricle become akinetic or hypocinetic, causing the heart to take on a shape resembling an octopus trap (**takotsubo**). *Restrictive cardiomyopathy* - This is a condition where the walls of the ventricles become **stiff** and **lose their flexibility**, preventing the heart from filling properly. - It is typically caused by conditions like **amyloidosis** or **sarcoidosis**, leading to impaired diastolic function, not transient stunning. *Subendocardial infarction* - This refers to a **heart attack** that affects only the **inner layer** of the heart muscle (**subendocardium**) due to reduced blood flow [2]. - It is a form of **acute coronary syndrome** where there is irreversible myocardial necrosis, unlike the temporary dysfunction in stunning [1]. *Transmural infarction* - This is a **severe form of heart attack** where the entire thickness of the heart muscle wall is affected, usually due to a **complete blockage of a coronary artery** [2]. - This also represents **acute coronary syndrome** with widespread myocardial necrosis, which is fundamentally different from a reversible stunning of the myocardium [1].

Q: A patient presents with palpitations, consciousness, fast pulse, and BP of 80/50 mmHg. After failed vagal maneuver and maximum dose of adenosine, what is the next step in management?

Cardioversion. ***Cardioversion*** - The patient presents with **symptomatic tachycardia** (palpitations, decreased consciousness, hypotension) refractory to **vagal maneuvers** and **adenosine**, indicating hemodynamic instability. - In such cases, **synchronized cardioversion** is the definitive treatment to restore sinus rhythm promptly and prevent further deterioration [1]. *Amiodarone* - **Amiodarone** is an antiarrhythmic drug used for stable wide complex tachycardia or as a second-line agent for unstable tachycardia after cardioversion. - It is not the immediate next step for an unstable patient who has failed adenosine, as its onset of action is slower than cardioversion [2]. *Repeat adenosine* - The question states that the patient has already received the **maximum dose of adenosine** and it has failed. - Administering more adenosine would be ineffective and delay definitive treatment for a hemodynamically unstable patient. *Defibrillation* - **Defibrillation** is used for **pulseless ventricular tachycardia/fibrillation** where there is no organized electrical activity [1]. - This patient has a pulse and an organized (though fast) rhythm, making synchronized cardioversion the appropriate electrical therapy.

Q: A patient presents with palpitations. On examination the patient was conscious, pulse was fast with BP of 80/50 mmHg. He was subjected to Vagal maneuver and was given intravenous adenosine. The rhythm remains refractory to maximum dose of adenosine. What is the next step in management of this patient?

Cardioversion. ***Cardioversion*** - As the patient is **hemodynamically unstable** (BP 80/50 mmHg) and has a **tachyarrhythmia** refractory to vagal maneuvers and maximal adenosine, **synchronized cardioversion** is the immediate next step. - This intervention provides a rapid and effective way to restore sinus rhythm in unstable supraventricular tachycardias (SVTs). *Repeat adenosine* - Adenosine has a very short half-life and its effects are transient; **repeated doses** beyond the maximal recommended dose are unlikely to be effective and may carry increased risk without benefit in a refractory case [2]. - The patient's **hemodynamic instability** necessitates a more definitive and immediate intervention than further pharmacotherapy. *Amiodarone* - While amiodarone is an **antiarrhythmic drug** used for tachyarrhythmias, it acts more slowly than cardioversion and is typically reserved for **hemodynamically stable** patients or after electrical cardioversion if arrhythmia recurs. - Given the patient's **hypotension**, immediate electrical cardioversion is prioritized over pharmacologic therapy that takes time to act. *Defibrillation* - Defibrillation is used for **pulseless ventricular tachyarrhythmias** (VT/VF) or cardiac arrest, which does not match the clinical scenario described as the patient has a pulse [1]. - This patient is in a **tachycardia with a pulse** and is hemodynamically unstable, requiring synchronized cardioversion rather than unsynchronized defibrillation.

Q: Deep y descent in JVP is seen in all except:

Cardiac tamponade. **Cardiac tamponade** - In **cardiac tamponade**, the heart’s filling is severely restricted by fluid in the pericardial sac, leading to an **elevated right atrial pressure** that impedes venous return and results in **blunting or absence of the y descent** in the JVP [1]. - The elevated pericardial pressure prevents the right ventricle from expanding during early diastole, which is the physiological basis for the **normal y descent**. *RCM* - **Restrictive cardiomyopathy (RCM)** is characterized by **impaired ventricular filling** during diastole, causing a rapid fall in atrial pressure after tricuspid valve opening, resulting in a **prominent and deep y descent**. - The rapid early diastolic filling during the y descent is abruptly halted as the stiff ventricle is unable to further accommodate blood, leading to a rapid rise in ventricular pressure. *Constrictive pericarditis* - In **constrictive pericarditis**, the rigid pericardium encases the heart, severely **restricting diastolic filling** and causing a rapid early diastolic drop in right atrial pressure, hence a **prominent and deep y descent** [2]. - Despite the rapid initial fall, the y descent is often followed by a rapid rise in pressure (square root sign on ventricular pressure tracing) as the heart reaches the limits of its constrained filling. *Tricuspid regurgitation* - While **tricuspid regurgitation** primarily impacts the **c-v wave** due to backflow into the atrium during ventricular systole, it can also present with an **exaggerated y descent** if there is significant diastolic dysfunction or associated conditions like right heart failure. - However, the most classic JVP finding in severe tricuspid regurgitation is a prominent **regurgitant c-v wave**, not necessarily a deep y descent as a primary feature.

Q: What is indicated by an 'enlarged left atrium' on echocardiography?

Chronic mitral regurgitation. ***Chronic mitral regurgitation*** - Long-standing **mitral regurgitation** causes chronic volume overload in the left atrium, leading to its **dilatation** as a compensatory mechanism [1]. - This **atrial enlargement** is a key indicator of the chronicity and significant hemodynamic impact of the valve lesion. *Tricuspid stenosis* - **Tricuspid stenosis** primarily impacts the **right atrium**, causing its enlargement due to obstruction of blood flow into the right ventricle. - It does not directly affect the left atrium, although severe right-sided heart disease can sometimes indirectly influence left-sided filling. *Acute mitral regurgitation* - In **acute mitral regurgitation**, there is insufficient time for the left atrium to remodel and dilate significantly in response to the sudden volume overload [1]. - While left atrial pressure rises dramatically, the atrium itself typically appears **normal in size** or only mildly enlarged. *Pulmonary embolism* - A **pulmonary embolism** primarily affects the **right side of the heart**, leading to sudden increases in **pulmonary artery pressure** and right ventricular strain. - It does not directly cause left atrial enlargement, though severe acute right heart failure can impact left ventricular filling.

Question 1

A person was brought to emergency department and was diagnosed with Supra ventricular tachycardia and suddenly he became unstable. What is the next line of management?

Accepted Answer

DC Cardioversion

Answer

Intravenous ibutilide

Answer

Intravenous Diltiazem

Answer

Intravenous Flecainide

Question 2

Which disease does not cause AV nodal block?

Accepted Answer

Cat scratch

Answer

Toxoplasmosis

Answer

Chagas

Answer

Lyme disease

Question 3

A man who is chronic alcoholic will develop which type of cardiomyopathy?

Accepted Answer

Dilated cardiomyopathy

Answer

Hypertrophic cardiomyopathy

Answer

Myocarditis

Answer

Pericarditis

Question 4

Pulmonary Plethora is seen in -

Accepted Answer

TAPVC

Answer

Tricuspid Atresia

Answer

CoA

Answer

TOF

Question 5

A 25-year-old female presented to ER unconscious. Her mother tells you about her having recurrent syncopal episodes. Her BP is 80/60 mm Hg and you order an ECG. Treatment is

Accepted Answer

DC shock

Answer

Cathether Ablation

Answer

Adenosine

Answer

Radiofrequency ablation

Question 6

Stunning of myocardium without any acute coronary syndrome is:-

Accepted Answer

Takotsubo cardiomyopathy

Answer

Restrictive cardiomyopathy

Answer

Subendocardial infarction

Answer

Transmural infarction

Question 7

A patient presents with palpitations, consciousness, fast pulse, and BP of 80/50 mmHg. After failed vagal maneuver and maximum dose of adenosine, what is the next step in management?

Accepted Answer

Cardioversion

Answer

Amiodarone

Answer

Repeat adenosine

Answer

Defibrillation

Question 8

A patient presents with palpitations. On examination the patient was conscious, pulse was fast with BP of 80/50 mmHg. He was subjected to Vagal maneuver and was given intravenous adenosine. The rhythm remains refractory to maximum dose of adenosine. What is the next step in management of this patient?

Accepted Answer

Cardioversion

Answer

Repeat adenosine

Answer

Amiodarone

Answer

Defibrillation

Question 9

Deep y descent in JVP is seen in all except:

Accepted Answer

Cardiac tamponade

Answer

RCM

Answer

Constrictive pericarditis

Answer

Tricuspid regurgitation

Question 10

What is indicated by an 'enlarged left atrium' on echocardiography?

Accepted Answer

Chronic mitral regurgitation

Answer

Tricuspid stenosis

Answer

Acute mitral regurgitation

Answer

Pulmonary embolism

Cardiology — MCQs

Cardiology — MCQs

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