Cardiology Practice Questions

Q: Patient shows ST depression, troponin rise 6h post-surgery. Next best step is:

Cardiology consult. ***Cardiology consult*** - A cardiology consult is the most appropriate next step given the presence of **ST depression** and a **troponin rise** post-surgery, indicating a likely myocardial infarction (MI). - This allows for prompt comprehensive evaluation, risk stratification, and initiation of specialized cardiac management by an expert. *12-lead ECG* - While a 12-lead ECG is an important diagnostic tool, the patient's existing **ST depression** suggests it has already been performed or noted. - A repeat ECG might be useful for tracking changes, but it doesn't replace the need for expert cardiac evaluation and management. *Echocardiogram* - An echocardiogram can assess **cardiac function**, wall motion abnormalities, and valvular issues, which are relevant in MI. - However, it's a diagnostic test that should be ordered and interpreted in the context of a broader cardiac workup, which a cardiologist can best coordinate. *Start heparin* - **Heparin** is an anticoagulant that may be part of the management for an MI, especially in certain types or for prevention of clot extension. - However, initiating anticoagulation should be done after a thorough assessment of the patient's cardiac status, bleeding risk post-surgery, and in consultation with cardiology, rather than as the immediate next best step.

Q: Which ECG change is most specific for acute pericarditis?

PR segment depression. ***PR segment depression*** - **PR segment depression** can be seen in approximately 80% of patients with acute pericarditis and is considered the **most specific ECG marker** [2]. - This finding is due to inflammation of the atria, causing altered atrial repolarization that manifests as depression of the **PR segment** in most leads (except aVR and V1, where it may be elevated). *T wave inversion* - **T wave inversion** typically occurs in later stages of pericarditis, after the resolution of ST-segment elevation [2]. - It is not specific to pericarditis and can be seen in various other conditions, including **myocardial ischemia** or infarction [1]. *Q waves* - The presence of **Q waves** usually indicates a transmural **myocardial infarction** and is not a feature of pericarditis [1]. - Pericarditis primarily affects the pericardium and typically does not cause myocardial necrosis that would result in pathological Q waves [1]. *ST segment elevation* - **ST segment elevation** is common in acute pericarditis, but it is typically generalized (diffuse) and concave upward, unlike the localized and convex upward ST elevation seen in **myocardial infarction** [1], [2]. - While present, its diffuse nature helps differentiate it from MI, but **PR depression** is a more specific marker [2].

Q: A 45-year-old female presents with dyspnea, orthopnea, and bilateral leg edema. Echo shows EF 35%. BNP 850 pg/mL. Which drug class has shown mortality benefit in this condition?

Beta blockers. ***Beta blockers*** - In **heart failure with reduced ejection fraction (HFrEF)**, beta blockers (e.g., carvedilol, metoprolol succinate, bisoprolol) significantly reduce **mortality** and hospitalizations [1]. - They work by blocking the adverse effects of **sympathetic nervous system activation** on the heart, improving cardiac remodeling and function over time. *Calcium channel blockers* - Non-dihydropyridine calcium channel blockers (e.g., verapamil, diltiazem) generally have **negative inotropic effects** and can worsen outcomes in HFrEF. - While some dihydropyridine calcium channel blockers (e.g., amlodipine) are considered safe, they do **not confer a mortality benefit** in this condition. *Alpha blockers* - Alpha blockers like prazosin are primarily used for **hypertension** and **benign prostatic hyperplasia**. - They have **not shown mortality benefit** in heart failure and may even cause symptomatic **hypotension**. *Nitrates* - Nitrates (e.g., isosorbide dinitrate, nitroglycerin) are effective **vasodilators** that reduce preload and afterload, alleviating symptoms like dyspnea [1]. - However, they do not consistently **reduce mortality** when used alone in HFrEF and are often combined with hydralazine for specific populations (e.g., African Americans).

Q: A 50-year-old patient presents with dyspnea, edema, and an elevated JVP. Which condition is most likely?

Right heart failure. ***Right heart failure*** - **Dyspnea**, **edema** (often peripheral), and an **elevated jugular venous pressure (JVP)** are classical signs of right heart failure due to systemic venous congestion [1]. - The inability of the right ventricle to pump blood efficiently leads to blood backing up in the systemic circulation [3]. *Left heart failure* - While it can cause dyspnea, left heart failure primarily leads to **pulmonary congestion** (e.g., crackles, orthopnea) and is less directly associated with prominent peripheral edema and elevated JVP as initial prominent symptoms [2]. - An elevated JVP and significant peripheral edema in left heart failure typically indicate progression to **biventricular failure** [1]. *Pneumonia* - Pneumonia typically presents with acute symptoms like **fever, cough with sputum, pleuritic chest pain**, and localized lung findings, rather than chronic dyspnea, edema, and elevated JVP. - It’s an **infectious lung condition**, not primarily a circulatory disorder causing systemic congestion. *Asthma* - Asthma is a **reversible obstructive airway disease** characterized by episodic **wheezing, cough, and shortness of breath** due to bronchospasm [4]. - It does not typically cause edema or an elevated JVP.

Q: Which condition is indicated by ST segment elevation in leads V1-V4?

Anterior myocardial infarction. ***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.

Q: Which finding on echocardiography suggests 'constrictive pericarditis'?

Pericardial thickening and septal bounce. ***Pericardial thickening and septal bounce*** - **Pericardial thickening** is a direct anatomical feature of constrictive pericarditis, indicating the fibrotic and inflamed state of the pericardium. - **Septal bounce**, or interventricular septal motion variation with respiration, is a highly specific sign of constriction, due to exaggerated ventricular interdependence. *Increased wall thickness* - This finding is more characteristic of **hypertrophic cardiomyopathy** or **hypertensive heart disease**, where the myocardial muscle itself thickens. - While it can impair diastolic function, it doesn't indicate a primary pericardial issue. *Global hypokinesis* - **Global hypokinesis** refers to reduced overall contractility of the heart muscle, typically seen in conditions like **dilated cardiomyopathy** or significant **ischemic heart disease**. - This indicates systolic dysfunction, whereas constrictive pericarditis primarily affects diastolic filling. *Pericardial effusion* - A **pericardial effusion** is an accumulation of fluid around the heart, which can cause **cardiac tamponade** if severe. - While effusions can sometimes precede or coexist with constrictive pericarditis, the fluid itself is not the hallmark of constriction, which is defined by a thickened, rigid pericardium.

Q: Which condition is suggested by the 'spade-shaped left ventricle' on ECHO?

Hypertrophic cardiomyopathy. ***Hypertrophic cardiomyopathy*** - A **spade-shaped left ventricle** is a classic echocardiographic finding in **hypertrophic cardiomyopathy (HCM)**, specifically apical HCM [3]. - This shape results from focal **hypertrophy of the left ventricular apex**, leading to a distinctive narrowing towards the apex [3]. *Aortic regurgitation* - Causes **left ventricular volume overload** and often leads to **left ventricular dilation**, not typically a spade shape [1]. - **Diastolic retrograde flow** across the aortic valve is the characteristic echocardiographic finding. *Pulmonary embolism* - Primarily affects the **right side of the heart**, leading to **right ventricular dilation** and **dysfunction** [1]. - Does not directly cause a **spade-shaped left ventricle**. *Dilated cardiomyopathy* - Characterized by **enlargement and thinning of all four heart chambers**, particularly the left ventricle [2]. - The left ventricle typically appears globally dilated and spherical, not spade-shaped [2].

Q: A 55-year-old male presents to the emergency department with chest pain. An ECG shows ST-segment depression in leads V2 and V3. Troponin levels are elevated. What is the most likely diagnosis?

NSTEMI. ***NSTEMI*** - Elevated **troponin levels** confirm myocardial infarction (myocardial cell necrosis), while **ST-segment depression** (and absence of ST elevation) indicates it is a non-ST elevation myocardial infarction [1]. - This condition is characterized by **ischemia** severe enough to cause myocardial damage, but not a complete transmural infarction. *Unstable angina* - Characterized by **chest pain at rest** or with minimal exertion, which is a new onset or worsening pattern of angina [1]. - Unlike NSTEMI, **troponin levels** would not be elevated, indicating no myocardial cell necrosis has occurred yet [1]. *STEMI* - Defined by **ST-segment elevation** in two contiguous leads on an ECG, indicating acute transmural myocardial ischemia [2]. - While troponin levels are elevated in STEMI, the absence of **ST elevation** on the ECG rules out this diagnosis [2]. *Posterior wall MI* - Often diagnosed by **ST-segment depression in leads V1-V3** and prominent R waves in those same leads, which are reciprocal changes for a posterior infarct. - The given information only states ST-segment depression in V2 and V3, and while a posterior MI can present this way, the most direct and overarching diagnosis given the troponin elevation and ST depression is NSTEMI.

Q: All of the following are features of hyperkalemia on ECG, EXCEPT:

U waves. ***U waves*** - **U waves** are typically associated with **hypokalemia**, not hyperkalemia. They are small deflections immediately following the T wave. - Their presence suggests an abnormality in myocardial repolarization due to low potassium levels. *Shortened QT interval* - A **shortened QT interval** is *not* a typical finding in hyperkalemia; hyperkalemia usually causes a **prolonged PR interval** and QRS widening, which can make QT measurement difficult but does not inherently shorten it. - A shortened QT interval is more commonly seen in conditions like **hypercalcemia** or inherited short QT syndrome. *Peaked T waves* - **Peaked T waves** (also known as "tenting" of the T waves) are one of the earliest and most classic ECG signs of hyperkalemia [1]. - This occurs due to abnormally rapid repolarization of the ventricles. *Wide QRS complex* - As hyperkalemia progresses, the **QRS complex widens** due to a slowing of intraventricular conduction [1]. - This widening can eventually lead to a **sine wave pattern** if not treated, indicating severe hyperkalemia and impending cardiac arrest.

Q: Which of the following is a characteristic hemodynamic finding in pericardial tamponade?

Pulsus paradoxus. ***Pulsus paradoxus*** - **Pulsus paradoxus** is a characteristic hemodynamic finding in pericardial tamponade, defined as a drop in **systolic blood pressure >10 mmHg** during inspiration. - This occurs due to **impaired ventricular filling** and exaggerated ventricular interdependence caused by the rigid pericardial constraint in tamponade. *Kussmaul sign* - **Kussmaul sign** (paradoxical rise in JVP during inspiration) is characteristically seen in **constrictive pericarditis**, not pericardial tamponade. - In tamponade, JVP typically shows a **monophasic descent** rather than the paradoxical rise seen with Kussmaul sign. *Beck's triad* - **Beck's triad** (hypotension, elevated JVP, muffled heart sounds) represents clinical **signs and symptoms** of tamponade, not a specific hemodynamic finding. - While present in tamponade, it describes the overall clinical presentation rather than a measurable hemodynamic parameter like pulsus paradoxus. *All of the options* - This is incorrect because **Kussmaul sign is not characteristic** of pericardial tamponade but rather of constrictive pericarditis. - Only **pulsus paradoxus** represents the specific hemodynamic finding that defines the physiological impairment in tamponade.

Question 1

Patient shows ST depression, troponin rise 6h post-surgery. Next best step is:

Accepted Answer

Cardiology consult

Answer

12-lead ECG

Answer

Echocardiogram

Answer

Start heparin

Question 2

Which ECG change is most specific for acute pericarditis?

Accepted Answer

PR segment depression

Answer

T wave inversion

Answer

Q waves

Answer

ST segment elevation

Question 3

A 45-year-old female presents with dyspnea, orthopnea, and bilateral leg edema. Echo shows EF 35%. BNP 850 pg/mL. Which drug class has shown mortality benefit in this condition?

Accepted Answer

Beta blockers

Answer

Calcium channel blockers

Answer

Alpha blockers

Answer

Nitrates

Question 4

A 50-year-old patient presents with dyspnea, edema, and an elevated JVP. Which condition is most likely?

Accepted Answer

Right heart failure

Answer

Left heart failure

Answer

Pneumonia

Answer

Asthma

Question 5

Which condition is indicated by ST segment elevation in leads V1-V4?

Accepted Answer

Anterior myocardial infarction

Answer

Posterior myocardial infarction

Answer

Lateral myocardial infarction

Answer

Inferior myocardial infarction

Question 6

Which finding on echocardiography suggests 'constrictive pericarditis'?

Accepted Answer

Pericardial thickening and septal bounce

Answer

Increased wall thickness

Answer

Global hypokinesis

Answer

Pericardial effusion

Question 7

Which condition is suggested by the 'spade-shaped left ventricle' on ECHO?

Accepted Answer

Hypertrophic cardiomyopathy

Answer

Aortic regurgitation

Answer

Pulmonary embolism

Answer

Dilated cardiomyopathy

Question 8

A 55-year-old male presents to the emergency department with chest pain. An ECG shows ST-segment depression in leads V2 and V3. Troponin levels are elevated. What is the most likely diagnosis?

Accepted Answer

NSTEMI

Answer

Unstable angina

Answer

STEMI

Answer

Posterior wall MI

Question 9

All of the following are features of hyperkalemia on ECG, EXCEPT:

Accepted Answer

U waves

Answer

Shortened QT interval

Answer

Peaked T waves

Answer

Wide QRS complex

Question 10

Which of the following is a characteristic hemodynamic finding in pericardial tamponade?

Accepted Answer

Pulsus paradoxus

Answer

Beck's triad

Answer

Kussmaul sign

Answer

All of the options

Cardiology — MCQs

Cardiology — MCQs

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