Cardiology Practice Questions

Q: A 45-year-old man presents with exertional dyspnea and swelling of his legs. An echocardiogram shows left ventricular hypertrophy and systolic dysfunction. What is the most likely underlying cause?

Ischemic heart disease. ***Ischemic heart disease*** - This condition is characterized by **reduced blood flow** to the heart, leading to **myocardial damage**, which can result in left ventricular hypertrophy and systolic dysfunction. - It can cause exertional dyspnea due to compromised heart function and may manifest as swelling in the legs due to heart failure [1][2]. *Hypertrophic cardiomyopathy* - Typically presents with **diastolic dysfunction** rather than systolic dysfunction, characterized by an **increased wall thickness** without the systolic failure observed here. - Symptoms include **syncope** during exertion but are less likely to cause leg swelling. *Aortic stenosis* - Often leads to **concentric left ventricular hypertrophy**; however, it primarily results in **outflow obstruction**, causing symptoms like chest pain and exertional dyspnea rather than systolic dysfunction directly. - Leg swelling is less common and typically occurs later in the course of heart failure due to aortic stenosis. *Dilated cardiomyopathy* - Characterized primarily by **systolic dysfunction** [2] but typically includes signs of **ballooning** of the ventricles rather than merely hypertrophy. - It often results from a variety of factors including **viral infections** or **alcohol abuse**, rather than just ischemic causes.

Q: Which medication is indicated for the long-term management of patients with stable ischemic heart disease to reduce the risk of myocardial infarction?

Antiplatelet agents. ***Antiplatelet agents*** - **Antiplatelet agents**, specifically **aspirin**, are crucial for long-term management in stable ischemic heart disease to prevent **thrombus formation** and reduce the risk of **myocardial infarction** and **stroke** [1]. - They inhibit **platelet aggregation**, a key step in the pathophysiology of atherothrombotic events. *Calcium channel blockers* - While effective for **symptomatic relief** of angina by causing **vasodilation** and reducing cardiac oxygen demand, they do not directly reduce the risk of **myocardial infarction** in stable ischemic heart disease [3]. - Their primary role is to improve **quality of life** by decreasing frequency and severity of angina attacks [2]. *Nitrates* - **Nitrates** are used for both acute and chronic relief of angina symptoms through **venodilation** and **coronary vasodilation**, which reduce **preload** and improve myocardial oxygen supply [1]. - However, they do not have a proven role in reducing the long-term risk of **myocardial infarction** or improving mortality outcomes in stable CAD. *Beta-blockers* - **Beta-blockers** are indicated for long-term management to reduce **angina symptoms** and improve outcomes after **myocardial infarction** by decreasing heart rate, blood pressure, and myocardial contractility, thereby reducing **myocardial oxygen demand** [3]. - While they reduce MI recurrence post-MI, their primary role in *stable* ischemic heart disease (without prior MI) is for symptom control rather than primary prevention of initial MI beyond their hemodynamic effects.

Q: Which murmur increases on standing?

HOCM. ***HOCM*** - Standing decreases **venous return** and **left ventricular volume**, which reduces the size of the LV outflow tract and thus exacerbates the obstruction in **hypertrophic obstructive cardiomyopathy (HOCM)**, making the murmur louder [1]. - This maneuver is a key diagnostic feature as reduced preload intensifies the dynamic obstruction. *MR* - **Mitral regurgitation (MR)** is typically a volume overload lesion, and standing (which reduces preload) generally causes the murmur to **decrease** in intensity due to less blood volume ejected back into the atrium [3]. - The murmur of MR is usually a holosystolic murmur radiating to the axilla [3]. *MS* - **Mitral stenosis (MS)** is a fixed obstruction to left ventricular filling. Changes in preload (like standing) do not significantly alter the gradient across the mitral valve or the intensity of the murmur [2]. - Its characteristic murmur is a **mid-diastolic rumble** with an opening snap [1]. *VSD* - A **ventricular septal defect (VSD)** murmur is caused by blood flowing from the high-pressure left ventricle to the low-pressure right ventricle. Standing, by reducing systemic vascular resistance, would typically cause the murmur to **decrease** in intensity as less blood shunts left-to-right. - The murmur is usually a **holosystolic murmur** best heard at the lower left sternal border.

Q: Identify the cardiac condition based on the ECG findings of a wide QRS complex tachycardia.

Ventricular tachycardia. ***Ventricular tachycardia*** - **Ventricular tachycardia (VT)** is a common cause of **wide QRS complex tachycardia**, originating from the ventricles. - The ECG typically shows a regular, rapid rhythm with **QRS complexes >0.12 seconds**. *Atrial fibrillation* - **Atrial fibrillation** presents as an **irregularly irregular rhythm** with no distinct P waves. - While it can manifest as tachycardia, the QRS complex is typically **narrow**, unless there is an accessory pathway or bundle branch block. *Atrial flutter* - **Atrial flutter** is characterized by a **"sawtooth" pattern of P waves** (flutter waves) in the inferior leads. - The ventricular rhythm can be regular or irregular, but the QRS complex is usually **narrow**. *Supraventricular tachycardia (SVT)* - **Supraventricular tachycardia (SVT)** typically presents with a **narrow QRS complex** (<0.12 seconds) as it originates above the ventricles. - A wide QRS can occur in SVT with **aberrancy** (e.g., bundle branch block), but ventricular tachycardia is a primary cause of wide QRS tachycardia.

Q: What is the immediate treatment for a hemodynamically unstable patient with supraventricular tachycardia (SVT)?

Cardioversion. ***Cardioversion*** * **Synchronized cardioversion** is the immediate treatment for hemodynamically **unstable** patients with **supraventricular tachycardia (SVT)** to quickly restore sinus rhythm and prevent cardiovascular collapse. * Hemodynamic instability includes symptoms such as **hypotension**, altered mental status, signs of shock, acute heart failure, or ischemic chest pain, directly caused by the arrhythmia. *Intravenous Diltiazem* * **Diltiazem** is a calcium channel blocker used for **rate control** in stable SVT, but it is not appropriate for unstable patients due to its slower onset of action and potential for further hypotension. * In hemodynamically unstable patients, delaying cardioversion to administer medications like diltiazem can worsen the patient's condition. *Intravenous Ibutilide* * **Ibutilide** is an antiarrhythmic drug used for recent-onset atrial fibrillation or flutter, but it is typically reserved for **hemodynamically stable** patients. * It is not the drug of choice for immediate management of unstable SVT as it has a slower onset and can potentially cause proarrhythmia. *Intravenous beta-blockers* * **Beta-blockers** are used for **rate control** in hemodynamically **stable** patients with SVT by blocking AV nodal conduction. * They are contraindicated in unstable patients as they can exacerbate hypotension, especially in those with reduced cardiac function.

Q: Identify the diagnosis based on the provided ECG image.

PSVT. ***PSVT*** - The ECG shows a **narrow complex tachycardia** with a regular rhythm and a high heart rate, characteristic of **paroxysmal supraventricular tachycardia (PSVT)**. - P waves are often **buried within the QRS complex** or T waves, or may be retrograde, which can be seen as small deflections or changes in the baseline in some leads. *VT* - **Ventricular tachycardia** is characterized by a **wide QRS complex** (>0.12 seconds), which is not observed in this ECG. - While VT can be regular, the primary distinguishing feature is the QRS duration. *AT* - **Atrial tachycardia (AT)** is another form of supraventricular tachycardia, but it typically shows **distinct P waves** with an abnormal morphology, often separate from the T wave, which are not clearly visible or consistently distinct in this tracing. - While it can present with narrow complex tachycardia, the mechanism differs from re-entrant PSVT. *Ventricular fibrillation* - **Ventricular fibrillation** is characterized by **chaotic, irregular electrical activity** with no distinguishable P waves, QRS complexes, or T waves, representing disorganized ventricular depolarization. - The ECG in the image shows a consistent, regular rhythm with identifiable, albeit narrow, QRS complexes.

Q: Identify the condition in the ECG based on the provided image.

Atrial flutter. ***Atrial flutter*** - The distinctive **sawtooth pattern** between QRS complexes is characteristic of atrial flutter, representing rapid and regular atrial depolarization. - The ventricular response here appears to be a 4:1 block, meaning every fourth flutter wave is conducted to the ventricles, resulting in a regular ventricular rhythm. *Atrial fibrillation* - Characterized by **irregularly irregular R-R intervals** and the absence of distinct P waves, replaced by chaotic fibrillatory waves. - The ECG shows a regular ventricular rhythm with clear flutter waves, which is not consistent with atrial fibrillation. *Arrhythmia* - This is a broad term for any abnormal heart rhythm. While atrial flutter is an arrhythmia, this option is too general and does not identify the specific condition. - The question asks to identify the specific condition, not just categorize it as an abnormal rhythm. *Cardiomyopathy* - Cardiomyopathy refers to diseases of the **heart muscle** that can lead to heart failure or arrhythmias, but it is a structural diagnosis, not an ECG rhythm diagnosis. - An ECG for cardiomyopathy might show signs like chamber enlargement, Q waves, or conduction disturbances, but not the specific sawtooth pattern seen in this tracing.

Q: Which condition is associated with the ECG pattern known as pseudo P pulmonale?

Hypercalcemia. ***Hypercalcemia*** - **Hypercalcemia** can cause a characteristic ECG pattern known as pseudo P pulmonale due to its effects on **myocardial repolarization**. - This condition leads to a **shortened QT interval** which causes the T wave to merge with the P wave, giving the appearance of a tall, peaked P wave. *Hypokalemia* - **Hypokalemia** typically presents with **flattened T waves**, prominent U waves, and ST-segment depression on an ECG [1]. - It can prolong repolarization, which is the opposite effect observed with pseudo P pulmonale [1]. *Hyponatremia* - **Hyponatremia** has a less defined direct effect on ECG patterns compared to other electrolyte imbalances. - Severe hyponatremia may lead to **QRS widening** or **bradycardia**, but not pseudo P pulmonale [1]. *Hypocalcemia* - **Hypocalcemia** characteristically causes **prolongation of the QT interval** on an ECG due to delayed ventricular repolarization [2]. - This is distinct from the shortened QT seen in hypercalcemia that contributes to pseudo P pulmonale.

Q: What is a potential cause of cardiogenic shock other than myocardial infarction (MI)?

Acute mitral regurgitation. ***Acute mitral regurgitation*** - **Acute mitral regurgitation** is a severe form of valvular heart disease where the mitral valve fails to close properly, leading to a sudden backflow of blood into the left atrium during systole. [1] - This significantly reduces **forward cardiac output** and increases left atrial pressure, which can rapidly lead to pulmonary edema and cardiogenic shock, even in the absence of MI. [1] *Ventricular septal rupture* - While a **ventricular septal rupture** can cause cardiogenic shock, it is typically a **complication of myocardial infarction**, meaning it would fall under MI as the underlying cause. [2] - This condition involves a hole in the septum separating the ventricles, leading to a shunt and increased workload on the right ventricle, causing cardiogenic shock. *Isolated right ventricular shock* - **Isolated right ventricular shock** is often caused by conditions like a **massive pulmonary embolism** or a right ventricular infarction. [2] - While it can lead to shock, it is distinct from general cardiogenic shock which often implies left ventricular dysfunction or severe myocardial compromise, and the question asks for a cause *other than* MI, which can cause right ventricular shock. *None of the options* - This option is incorrect because **acute mitral regurgitation** is a distinct and significant cause of cardiogenic shock, independent of MI. [1]

Q: At what time frame does peripartum cardiomyopathy typically occur?

Within 5 months of delivery. ***Within 5 months of delivery*** - **Peripartum cardiomyopathy** is defined as the development of heart failure with **left ventricular systolic dysfunction** occurring during the **last month of pregnancy or within five months after delivery**. - The postpartum component extends up to **5 months (approximately 20 weeks)** after delivery, making this the most complete answer among the given options. - This timeframe is essential for differentiating **peripartum cardiomyopathy** from other forms of cardiomyopathy. *Within 6 weeks of delivery* - While this represents the traditional postpartum period and many cases do present within 6 weeks, the diagnostic definition of **peripartum cardiomyopathy** extends further to **5 months postpartum**. - This narrower timeframe would miss cases presenting between 6 weeks and 5 months, thus not encompassing the full diagnostic criteria. *Within 24 months of delivery* - This timeframe significantly exceeds the established diagnostic window for **peripartum cardiomyopathy**. - Heart failure presenting beyond 5 months postpartum would likely be classified as **dilated cardiomyopathy** or another form of cardiomyopathy with different underlying causes. *Within 7 days of delivery* - This is too narrow a window and represents only the immediate postpartum period. - While some cases can present acutely in the first week, the diagnostic definition allows for onset up to **5 months postpartum**, and limiting it to 7 days would miss the majority of cases.

Question 1

A 45-year-old man presents with exertional dyspnea and swelling of his legs. An echocardiogram shows left ventricular hypertrophy and systolic dysfunction. What is the most likely underlying cause?

Accepted Answer

Ischemic heart disease

Answer

Hypertrophic cardiomyopathy

Answer

Aortic stenosis

Answer

Dilated cardiomyopathy

Question 2

Which medication is indicated for the long-term management of patients with stable ischemic heart disease to reduce the risk of myocardial infarction?

Accepted Answer

Antiplatelet agents

Answer

Calcium channel blockers

Answer

Nitrates

Answer

Beta-blockers

Question 3

Which murmur increases on standing?

Accepted Answer

HOCM

Answer

MR

Answer

MS

Answer

VSD

Question 4

Identify the cardiac condition based on the ECG findings of a wide QRS complex tachycardia.

Accepted Answer

Ventricular tachycardia

Answer

Atrial fibrillation

Answer

Atrial flutter

Answer

Supraventricular tachycardia (SVT)

Question 5

What is the immediate treatment for a hemodynamically unstable patient with supraventricular tachycardia (SVT)?

Accepted Answer

Cardioversion

Answer

Intravenous Diltiazem

Answer

Intravenous Ibutilide

Answer

Intravenous beta-blockers

Question 6

Identify the diagnosis based on the provided ECG image.

Accepted Answer

PSVT

Answer

VT

Answer

AT

Answer

Ventricular fibrillation

Question 7

Identify the condition in the ECG based on the provided image.

Accepted Answer

Atrial flutter

Answer

Atrial fibrillation

Answer

Arrhythmia

Answer

Cardiomyopathy

Question 8

Which condition is associated with the ECG pattern known as pseudo P pulmonale?

Accepted Answer

Hypercalcemia

Answer

Hyponatremia

Answer

Hypocalcemia

Answer

Hypokalemia

Question 9

What is a potential cause of cardiogenic shock other than myocardial infarction (MI)?

Accepted Answer

Acute mitral regurgitation

Answer

Ventricular septal rupture

Answer

Isolated right ventricular shock

Answer

None of the options

Question 10

At what time frame does peripartum cardiomyopathy typically occur?

Accepted Answer

Within 5 months of delivery

Answer

Within 6 weeks of delivery

Answer

Within 24 months of delivery

Answer

Within 7 days of delivery

Cardiology — MCQs

Cardiology — MCQs

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