Cardiology Practice Questions

Q: A patient presents with palpitations, chest pain, and irregular pulse. ECG shows irregular RR intervals with no P waves. Diagnosis?

Atrial fibrillation. Atrial fibrillation - Irregularly irregular RR intervals on ECG, combined with the absence of discernible P waves, are hallmark features of atrial fibrillation [2]. - The symptoms of palpitations and chest pain are common presentations due to the rapid and disorganized atrial electrical activity. Atrial flutter - Characterized by a "sawtooth" pattern of P waves (flutter waves), particularly prominent in leads II, III, aVF, which are absent here [3]. - While it can cause palpitations and an irregular pulse, the RR intervals often show a fixed block ratio, giving it a more regular rhythm unless conducted variably. SVT (Supraventricular Tachycardia) - Typically presents with a narrow QRS complex tachycardia and a regular rhythm, although some forms can be irregular. - P waves are often hidden within the QRS complex or appear retrograde, but the irregular RR intervals with no P waves are not characteristic. Ventricular tachycardia - Characterized by wide QRS complexes (typically >0.12 seconds) due to ventricular origin [1]. - While it causes palpitations and chest pain and can be irregular, the ECG description of no P waves with irregular RR intervals specifically points away from this diagnosis, which usually involves a rapid ventricular rhythm [1].

Q: A 55-year-old diabetic presents with chest pain, shortness of breath, and diaphoresis that began 1 hour ago. He has no history of prior stroke, recent surgery, or other contraindications to fibrinolysis. ECG shows ST elevation. A PCI-capable catheterization laboratory is immediately available and primary PCI can be performed within the guideline-recommended timeframe. What is the next best step?

PCI. ***PCI (Percutaneous Coronary Intervention)*** - The patient's symptoms (chest pain, shortness of breath, diaphoresis) combined with **ST elevation on ECG** indicate an **ST-segment elevation myocardial infarction (STEMI)**. - **PCI** is the preferred and most effective treatment for STEMI when available within the guideline-recommended timeframe. At PCI-capable centers, the target is a **door-to-balloon time of ≤90 minutes**; the broader **120-minute threshold** refers to the maximum acceptable time from first medical contact to PCI when considering transfer to a PCI-capable facility — beyond which thrombolysis should be considered instead. - Because a PCI-capable laboratory is immediately available here, primary PCI is the clear preferred strategy. *Nitroglycerin* - While nitroglycerin can help alleviate chest pain by causing **vasodilation**, it does not address the underlying coronary artery occlusion in STEMI. - It is typically used for symptomatic relief in **angina** or NSTEMI, but not as the primary reperfusion therapy for STEMI. *Thrombolysis* - **Thrombolysis** is an alternative reperfusion strategy for STEMI when PCI is not readily available or cannot be performed within **120 minutes of first medical contact** (the PCI strategy threshold). At PCI-capable centers with a door-to-balloon target of ≤90 minutes, thrombolysis is not preferred. - In this case, the patient presents within 1 hour of symptom onset and has no contraindications to fibrinolysis; however, because timely primary PCI is immediately available, **PCI is superior to thrombolysis** in terms of revascularization success and clinical outcomes. *Heparin* - **Heparin** is an anticoagulant used as an adjunct therapy in STEMI to prevent further clot formation and propagation. - It is part of the overall management strategy but does not directly open the occluded artery and is not a primary reperfusion therapy on its own.

Q: A 55-year-old diabetic man presents to a PCI-capable hospital with chest pain, shortness of breath, and diaphoresis for the past 2 hours. ECG shows ST elevation. The estimated door-to-balloon time at this facility is 65 minutes. What is the next best step in management?

PCI. ***PCI*** - **Primary PCI** is the preferred reperfusion strategy for **ST-elevation myocardial infarction (STEMI)** when performed within **90 minutes** of door-to-balloon time at a PCI-capable hospital. - This patient's presentation (chest pain, shortness of breath, diaphoresis) with **ST elevation on ECG** confirms acute STEMI, making PCI the most effective treatment to restore coronary blood flow. *Thrombolysis* - Thrombolysis is a **second-line reperfusion strategy** reserved for when **primary PCI is not available** within the recommended 90-minute timeframe. - Since this patient is at a **PCI-capable hospital** with a door-to-balloon time of 65 minutes (within guidelines), PCI is superior to thrombolysis. *Nitroglycerin* - Nitroglycerin provides **symptom relief** through vasodilation and reducing cardiac preload, but does not address the underlying **coronary artery occlusion**. - It serves as an **adjunctive therapy** but cannot restore reperfusion to the ischemic myocardium in STEMI. *Heparin* - Heparin is an important **anticoagulant** used to prevent further clot formation and propagation in STEMI management. - It is **adjunctive therapy** that does not directly restore blood flow by removing or dissolving the occluding thrombus like reperfusion strategies.

Q: A 30-year-old female presents with exertional dyspnea and a loud P2 on auscultation. What is the most likely diagnosis?

Pulmonary hypertension. ***Pulmonary hypertension*** - **Exertional dyspnea** is a common symptom due to increased pulmonary vascular resistance leading to right heart strain [1]. - A **loud P2** (second heart sound, pulmonary component) indicates elevated pulmonary artery pressure [1]. *Mitral regurgitation* - Characterized by a **holosystolic murmur** best heard at the apex and radiating to the axilla. - While it can cause dyspnea, a loud P2 is not a primary or specific finding. *Aortic stenosis* - Presents with a **systolic ejection murmur** heard best at the right upper sternal border, radiating to the carotids [2]. - Symptoms include dyspnea, angina, and syncope, but a loud P2 is not typically associated [2]. *Pericarditis* - Typically causes **sharp chest pain** that improves with leaning forward and a **pericardial friction rub**. - Dyspnea may occur but is usually related to pain or tamponade, and a loud P2 is not a characteristic sign.

Q: Which condition is indicated by 'Q waves' and 'ST elevation' in leads II, III, and aVF?

Inferior myocardial infarction. Current ECG leads II, III, and aVF reflect the electrical activity of the inferior wall of the left ventricle [2]. Inferior myocardial infarction is typically indicated by ST elevation and subsequent Q wave formation in these leads [2], [3]. Q waves indicate necrosis (infarction), and ST elevation signifies acute ischemia in the myocardial territory often supplied by the right coronary artery (RCA) [3]. Lateral myocardial infarction typically manifests with changes in leads I, aVL, V5, and V6, which correspond to the lateral ventricular wall [2]. In contrast, an anterior myocardial infarction is characterized by changes, including Q waves and ST elevation, in leads V1, V2, V3, and V4 [1]. Pericarditis typically presents with diffuse ST elevation across multiple leads and does not typically involve the formation of pathological Q waves.

Q: A 65-year-old female with a history of heart failure presents with new-onset ascites and peripheral edema. What is the most likely underlying cause of her ascites?

Increased right atrial pressure. ***Increased right atrial pressure*** - In heart failure, especially **right-sided heart failure**, elevated right atrial pressure leads to increased pressure in the **systemic venous circulation** [1]. - This increased hydrostatic pressure in the **hepatic sinusoids** and peripheral capillaries drives fluid extravasation into the peritoneal cavity (ascites) and interstitial spaces (edema). *Impaired left ventricular function* - While impaired left ventricular function is central to heart failure, it primarily causes **pulmonary congestion** and symptoms like dyspnea [1]. - It does not directly explain **ascites and peripheral edema** as the primary mechanism, which are more characteristic of right-sided failure or elevated systemic venous pressure [1]. *Reduced oncotic pressure due to liver disease* - Reduced oncotic pressure, typically caused by decreased **albumin synthesis** in significant **liver disease**, can lead to ascites and edema. - However, the patient's history of **heart failure** points to a cardiac origin for the fluid retention, not primary liver pathology. *Thrombosis of the portal vein* - **Portal vein thrombosis** causes **portal hypertension**, leading to ascites. - However, it typically does not cause generalized **peripheral edema** as seen here, and the patient's history of heart failure provides a more direct explanation for both ascites and edema.

Q: A 65M presents with worsening dyspnea and leg swelling. Physical examination reveals an elevated jugular venous pressure and bilateral lower extremity pitting edema. Most likely cause of his symptoms?

Right-sided heart failure. Right-sided heart failure - **Elevated jugular venous pressure (JVP)** and **bilateral lower extremity pitting edema** are classic signs of fluid overload due to the inability of the right ventricle to effectively pump blood [2], [4]. - **Dyspnea** can occur due to congestion in the lungs (if left-sided failure is also present) or due to increased effort of breathing with significant fluid retention [1], [3]. *Hypothyroidism* - While **hypothyroidism** can cause **non-pitting edema** (myxedema), it does not typically lead to elevated JVP. - The dyspnea in hypothyroidism is often related to respiratory muscle weakness or pleural effusions, not primarily venous congestion. *Chronic kidney disease* - **Chronic kidney disease** can cause **fluid overload** and **edema**, but it typically presents with **pitting edema** and elevated JVP. - However, the primary cause of the fluid retention in CKD is impaired renal excretion, not cardiac pump dysfunction, as in this case. *Liver cirrhosis* - **Liver cirrhosis** can lead to **ascites** and **peripheral edema** due to low albumin and portal hypertension. - Elevate JVP is not a typical feature of cirrhosis unless there is a co-existing cardiac condition.

Q: Which of the following is the most common cause of acute dyspnea in elderly adults?

Congestive heart failure. ***Congestive heart failure*** - **Congestive heart failure (CHF)** is a common cause of **acute dyspnea** in elderly adults due to the age-related decline in **cardiac function** and increased prevalence of comorbidities like **hypertension** and **coronary artery disease** [1]. - Symptoms typically include **orthopnea**, **paroxysmal nocturnal dyspnea**, and **peripheral edema**, often with a history of cardiac disease [1], [2]. *Asthma* - While asthma can cause acute dyspnea, it is less common as a *primary new onset* cause of acute dyspnea in the elderly compared to CHF. [2] - Asthma often presents with **wheezing**, **cough**, and a history of allergic reactions or childhood onset [2]. *Pulmonary embolism* - **Pulmonary embolism (PE)** is a serious cause of acute dyspnea but is less common overall than CHF in the elderly population as the *most frequent* cause. - Symptoms often include sudden onset of **dyspnea**, **pleuritic chest pain**, and sometimes **hemoptysis**, along with risk factors like recent surgery or prolonged immobility. *Pneumothorax* - **Pneumothorax** is an acute and severe cause of dyspnea, but it is relatively less common than CHF and typically presents with **sudden unilateral chest pain** and shortness of breath. - It is often associated with pre-existing lung disease (e.g., COPD) or trauma, rather than being a frequent primary cause of acute dyspnea in the general elderly population.

Q: A 65-year-old man with congestive heart failure presents with worsening bilateral pitting edema. What is the most appropriate next step in management?

Increase diuretic dose. ***Increase diuretic dose*** - Worsening **pitting edema** in a patient with **congestive heart failure** indicates fluid overload, and increasing the diuretic dose is the most direct and effective treatment [1]. - This aims to **reduce fluid retention** and alleviate symptoms like edema and congestion, improving the patient's hemodynamic status [1]. *Add beta-blocker* - Beta-blockers are crucial for **long-term management** of heart failure by improving cardiac function and survival, but they are typically initiated slowly in stable patients. - Adding a beta-blocker acutely in a patient with worsening fluid overload can exacerbate symptoms and is generally **contraindicated** if the patient is not euvolemic. *Start corticosteroids* - **Corticosteroids** have powerful **anti-inflammatory** and immunosuppressive effects but are not indicated for the management of fluid overload in heart failure [1]. - They can actually cause **sodium and fluid retention**, which would worsen the patient's edema and heart failure symptoms [1]. *Prescribe ACE inhibitor* - **ACE inhibitors** are foundational in heart failure therapy for reducing afterload and remodeling, but they do not directly address acute fluid overload [2]. - While beneficial for long-term management, initiating or increasing an ACE inhibitor would not be the most appropriate immediate step for acute worsening edema [2].

Question 1

A patient presents with palpitations, chest pain, and irregular pulse. ECG shows irregular RR intervals with no P waves. Diagnosis?

Accepted Answer

Atrial fibrillation

Answer

Atrial flutter

Answer

SVT

Answer

Ventricular tachycardia

Question 2

A 55-year-old diabetic presents with chest pain, shortness of breath, and diaphoresis that began 1 hour ago. He has no history of prior stroke, recent surgery, or other contraindications to fibrinolysis. ECG shows ST elevation. A PCI-capable catheterization laboratory is immediately available and primary PCI can be performed within the guideline-recommended timeframe. What is the next best step?

Accepted Answer

PCI

Answer

Nitroglycerin

Answer

Thrombolysis

Answer

Heparin

Question 3

A 55-year-old diabetic man presents to a PCI-capable hospital with chest pain, shortness of breath, and diaphoresis for the past 2 hours. ECG shows ST elevation. The estimated door-to-balloon time at this facility is 65 minutes. What is the next best step in management?

Accepted Answer

PCI

Answer

Nitroglycerin

Answer

Thrombolysis

Answer

Heparin

Question 4

A 30-year-old female presents with exertional dyspnea and a loud P2 on auscultation. What is the most likely diagnosis?

Accepted Answer

Pulmonary hypertension

Answer

Mitral regurgitation

Answer

Aortic stenosis

Answer

Pericarditis

Question 5

Which condition is indicated by 'Q waves' and 'ST elevation' in leads II, III, and aVF?

Accepted Answer

Inferior myocardial infarction

Answer

Lateral myocardial infarction

Answer

Pericarditis

Answer

Anterior myocardial infarction

Question 6

Which of the following statements about atrial fibrillation is correct?

Accepted Answer

Discrepancy in pulse rate and heart rate are reliable for diagnosis

Answer

Rarely seen in heart with normal morphology

Answer

Cardioversion is used for all cases of atrial fibrillation

Answer

Only digoxin used for rate control

Question 7

A 65-year-old female with a history of heart failure presents with new-onset ascites and peripheral edema. What is the most likely underlying cause of her ascites?

Accepted Answer

Increased right atrial pressure

Answer

Impaired left ventricular function

Answer

Reduced oncotic pressure due to liver disease

Answer

Thrombosis of the portal vein

Question 8

A 65M presents with worsening dyspnea and leg swelling. Physical examination reveals an elevated jugular venous pressure and bilateral lower extremity pitting edema. Most likely cause of his symptoms?

Accepted Answer

Right-sided heart failure

Answer

Hypothyroidism

Answer

Chronic kidney disease

Answer

Liver cirrhosis

Question 9

Which of the following is the most common cause of acute dyspnea in elderly adults?

Accepted Answer

Congestive heart failure

Answer

Asthma

Answer

Pulmonary embolism

Answer

Pneumothorax

Question 10

A 65-year-old man with congestive heart failure presents with worsening bilateral pitting edema. What is the most appropriate next step in management?

Accepted Answer

Increase diuretic dose

Answer

Add beta-blocker

Answer

Start corticosteroids

Answer

Prescribe ACE inhibitor

Cardiology — MCQs

Cardiology — MCQs

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