Cardiology — MCQs
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Antibiotic prophylaxis for infective endocarditis is indicated in which of the following conditions?
Antibiotic prophylaxis for infective endocarditis is indicated in which of the following conditions?
A patient with hypertension is taking anti-hypertensive drugs but BP is not controlled even after adding diuretics in treatment. Patient's serum electrolyte shows hypokalemia. What is the next step in treatment of this patient?
A patient with known rheumatic heart disease is now found to have a 1–2 cm aneurysm on imaging. What is the most appropriate next step in management?
A 39-year-old male with symptoms of stress and work-life imbalance is diagnosed with Stage 2 hypertension (blood pressure 150/95 mmHg on three separate occasions) and impaired fasting glucose (120 mg/dL). What is the most appropriate pharmacological management?
A female patient complains of chest pain while waking up in the morning. Pain is more in winter months. Which of the following best describes this patient?
A patient after MI develops a broad QRS complex tachycardia. His BP is 120/85 mm Hg. ECG is given below. Best management?
A patient presents to the ER with central chest pain. He has a past medical history of heart disease. ECG is shown below. What is the diagnosis?
A patient with a history of rheumatic fever presents with a loud S1 and a low-pitched mid-diastolic murmur at the apex (best heard with the patient in the left lateral position). What is the most likely diagnosis?
A 25-year-old female with a previous history of rheumatic fever. Examination shows a loud S1 and mid-diastolic murmur. Which of the following valvular heart diseases does she have?
Cardiology Indian Medical PG Practice Questions and MCQs
Question 1161: Antibiotic prophylaxis for infective endocarditis is indicated in which of the following conditions?
- A. Isolated secundum atrial septal defect (ASD)
- B. Mitral valve prolapse without regurgitation
- C. Prior coronary artery bypass graft
- D. Coarctation of the aorta (Correct Answer)
Explanation: **Explanation:** The current guidelines (AHA/ACC and ESC) have significantly narrowed the indications for antibiotic prophylaxis to prevent Infective Endocarditis (IE) [1]. Prophylaxis is now reserved only for patients with the **highest risk** of adverse outcomes from IE undergoing high-risk dental procedures. **Why Coarctation of the Aorta is Correct:** **Coarctation of the aorta** is classified under **Cyanotic Congenital Heart Disease (CHD)** or complex CHD categories that require prophylaxis if they involve prosthetic material or remain unrepaired [1]. In the context of NEET-PG, high-risk categories include: 1. Prosthetic heart valves (including TAVI). 2. Prior history of Infective Endocarditis. 3. Unrepaired cyanotic CHD (including palliative shunts/conduits). 4. Repaired CHD with prosthetic material (first 6 months post-op). 5. Cardiac transplant recipients with valve regurgitation. **Why Incorrect Options are Wrong:** * **A. Isolated Secundum ASD:** This is a low-pressure shunt with minimal turbulence. It does not require prophylaxis. * **B. Mitral Valve Prolapse (MVP) without regurgitation:** Even MVP with regurgitation [3] is no longer recommended for prophylaxis under current guidelines, as the risk of IE is low compared to the risk of antibiotic side effects [1][2]. * **C. Prior CABG:** Coronary artery bypass grafts do not involve the endocardial surface or heart valves directly in a way that increases IE risk; therefore, prophylaxis is not indicated. **High-Yield Clinical Pearls for NEET-PG:** * **Prophylaxis is ONLY recommended for dental procedures** involving manipulation of gingival tissue or the periapical region of teeth [2]. * **NOT recommended** for routine GI or GU procedures (e.g., endoscopy, colonoscopy) unless an active infection is being treated. * **Drug of Choice:** Oral **Amoxicillin (2g)** 30–60 minutes before the procedure. If allergic to penicillin, use **Clindamycin (600mg)** or Azithromycin/Clarithromycin (500mg).
Question 1162: Antibiotic prophylaxis for infective endocarditis is indicated in which of the following conditions?
- A. Isolated secundum atrial septal defect (ASD)
- B. Mitral valve prolapse without regurgitation
- C. Prior coronary artery bypass graft
- D. Coarctation of the aorta (Correct Answer)
Explanation: ### Explanation The current guidelines for **Infective Endocarditis (IE) prophylaxis** (AHA/ESC) have become significantly more restrictive, focusing only on patients with the highest risk of adverse outcomes from IE. [1] **Why Coarctation of the Aorta is Correct:** Under the updated guidelines, antibiotic prophylaxis is indicated for **Cyanotic Congenital Heart Disease (CHD)** that has not been repaired, or for 6 months following a repair using prosthetic material. However, **Coarctation of the Aorta** is a high-turbulence lesion. While some modern guidelines have downgraded it, in the context of NEET-PG and standard medical examinations, it remains categorized under "High-risk" or "Complex Congenital Heart Disease" requiring prophylaxis, especially if associated with a bicuspid aortic valve or prosthetic repair. **Analysis of Incorrect Options:** * **A. Isolated Secundum ASD:** This is a low-pressure, low-turbulence lesion. The endothelial damage required for vegetation formation is minimal; hence, prophylaxis is **not** recommended. * **B. Mitral Valve Prolapse (MVP) without regurgitation:** MVP, even with regurgitation, is no longer an indication for prophylaxis. The risk of IE in MVP is low compared to the risks of antibiotic resistance and anaphylaxis. [1] * **C. Prior CABG:** Coronary artery bypass grafts are vascular procedures involving vessels, not the endocardium or heart valves. They do not increase the risk of IE. **High-Yield Clinical Pearls for NEET-PG:** * **Indications for IE Prophylaxis:** 1. Prosthetic heart valves (including TAVI). [1] 2. Prosthetic material used for cardiac valve repair (annuloplasty rings/cords). 3. Previous history of Infective Endocarditis. 4. Unrepaired cyanotic CHD or repaired CHD with residual shunts/valvular regurgitation at the site of a prosthetic patch. * **Procedure of Choice:** Prophylaxis is only recommended for **dental procedures** involving manipulation of gingival tissue or the periapical region of teeth. [1] * **Drug of Choice:** **Amoxicillin** (2g orally 30–60 mins before the procedure). If allergic to Penicillin, use **Clindamycin** (600mg) or Azithromycin/Clarithromycin (500mg).
Question 1163: A patient with hypertension is taking anti-hypertensive drugs but BP is not controlled even after adding diuretics in treatment. Patient's serum electrolyte shows hypokalemia. What is the next step in treatment of this patient?
- A. KCL
- B. Hydrochlorothiazide
- C. Spironolactone (Correct Answer)
- D. Torasemide
Explanation: ***Spironolactone*** - The combination of **resistant hypertension** (uncontrolled BP despite standard therapy including a diuretic) and **hypokalemia** strongly suggests **Primary Aldosteronism**. - **Spironolactone** is an **aldosterone antagonist** (potassium-sparing diuretic) and is the drug of choice for treating hypertension secondary to hyperaldosteronism, as it corrects both the hypokalemia and the high blood pressure [1]. *KCL* - **Potassium chloride** (KCL) would correct the hypokalemia temporarily, but it does not address the underlying cause (aldosterone excess) or control the **resistant hypertension** [1]. - Supplementation alone is insufficient when the source of hypokalemia is excessive renal potassium loss driven by high aldosterone levels. *Torasemide* - **Torasemide** is a **loop diuretic**; adding it to the regimen will significantly increase potassium excretion, thereby **worsening the existing hypokalemia**. - Loop diuretics are potent potassium-wasting agents and are contraindicated when the suspicion is high for Primary Aldosteronism presenting with hypokalemia. *Hydrochlorothiazide* - **Hydrochlorothiazide** (HCTZ) is a **thiazide diuretic** (also a potassium-wasting drug). - Similar to Torasemide, adding HCTZ would exacerbate the **hypokalemia** and is not the appropriate therapy for hypertension suspected to be caused by mineralocorticoid excess.
Question 1164: A patient with known rheumatic heart disease is now found to have a 1–2 cm aneurysm on imaging. What is the most appropriate next step in management?
- A. IV antibiotics (Correct Answer)
- B. Aspirin for 3 weeks
- C. Aspirin lifelong
- D. Aspirin + Clopidogrel
Explanation: ***IV antibiotics*** - In a patient with **rheumatic heart disease (RHD)**, the finding of an aneurysm on imaging should raise strong suspicion for a **mycotic aneurysm**, especially given the increased risk of **infective endocarditis (IE)** in RHD patients [1]. - **Mycotic aneurysms** are infected arterial wall dilations that occur as a complication of IE, resulting from septic emboli or direct bacterial invasion of the vessel wall [2]. - **First-line management** consists of **prolonged IV antibiotics** (4-6 weeks) targeting the causative organism, along with close monitoring for aneurysm expansion or rupture. - Blood cultures, echocardiography, and infectious disease consultation are essential components of the workup [1]. *Aspirin lifelong* - While **aspirin** is important for long-term secondary prevention in RHD patients to reduce thromboembolic risk, it is **not the immediate priority** when an aneurysm is discovered. - In the setting of a **mycotic aneurysm**, aspirin may actually **increase bleeding risk** if the aneurysm ruptures and should be used cautiously [3]. - Long-term antiplatelet therapy would be considered after the acute infectious complication is addressed. *Aspirin + Clopidogrel* - **Dual antiplatelet therapy (DAPT)** is reserved for acute coronary syndromes or post-percutaneous coronary intervention, not for routine management of aneurysms in RHD. - In the context of a potential **mycotic aneurysm**, DAPT would significantly increase the risk of **catastrophic bleeding** without providing benefit. *Aspirin for 3 weeks* - Short-term aspirin therapy does not address the underlying pathology of a **mycotic aneurysm**, which requires targeted antimicrobial therapy. - This duration is insufficient for either treating the infection or providing adequate long-term vascular protection in RHD.
Question 1165: A 39-year-old male with symptoms of stress and work-life imbalance is diagnosed with Stage 2 hypertension (blood pressure 150/95 mmHg on three separate occasions) and impaired fasting glucose (120 mg/dL). What is the most appropriate pharmacological management?
- A. Start thiazide diuretic
- B. Advise rest only, no pharmacological treatment
- C. Start glucocorticoids
- D. Start telmisartan (Correct Answer)
Explanation: Start telmisartan - **Telmisartan** is an Angiotensin II Receptor Blocker (ARB), the most appropriate first-line choice for treating **Stage 2 hypertension** (150/95 mmHg) in patients with metabolic risk factors like **impaired fasting glucose**. [1] - ARBs are **metabolically neutral or beneficial**, providing cardiovascular protection and reducing progression to diabetes in patients with prediabetes. [1] - They offer **renal protection** (nephropathy prevention), which is crucial in patients at risk for developing diabetes mellitus. [1] - ARBs and ACE inhibitors are preferred over other antihypertensives in patients with metabolic syndrome. [1] *Start glucocorticoids* - Glucocorticoids are **absolutely contraindicated** in hypertension management and would severely worsen both conditions. - They cause **iatrogenic hypertension** and **hyperglycemia**, potentially precipitating diabetes mellitus. - This option represents a dangerous treatment choice with no role in this clinical scenario. *Start thiazide diuretic* - While thiazide diuretics are effective antihypertensives and commonly used first-line agents, they have **adverse metabolic effects**. [1] - Thiazides can worsen **glucose tolerance** and precipitate diabetes in prediabetic patients. [1] - They may also cause **dyslipidemia** and worsen metabolic syndrome components. - In patients with impaired fasting glucose, ARBs/ACE inhibitors are preferred due to their superior metabolic profile. [1] *Advise rest only, no pharmacological treatment* - **Stage 2 hypertension** (≥140/90 mmHg) with confirmed multiple elevated readings requires **immediate pharmacological therapy** alongside lifestyle modifications. - While addressing stress and work-life balance through lifestyle changes is important, these measures alone are insufficient for Stage 2 hypertension. - Delaying treatment increases cardiovascular risk, including stroke, myocardial infarction, and heart failure. [1] - Current guidelines (ACC/AHA, ESC/ESH) mandate pharmacological intervention for Stage 2 hypertension at initial diagnosis. [1]
Question 1166: A female patient complains of chest pain while waking up in the morning. Pain is more in winter months. Which of the following best describes this patient?
- A. Ach-induced coronary vasoconstriction (Correct Answer)
- B. Fixed plaque obstruction
- C. Increased sympathomimetic drive in morning hours
- D. Subendocardial ischemia due to increased demand of myocardium
Explanation: ***Ach-induced coronary vasoconstriction***- This clinical presentation—chest pain at rest (especially in the morning hours) and exacerbation during winter months (due to cold exposure)—is the hallmark of **Variant (Prinzmetal's) angina**, which is caused by transient **coronary vasospasm**. [1]- The mechanism involves underlying endothelial dysfunction leading to hyperreactivity of coronary smooth muscle, which can be demonstrated via provoked spasm using agents like **Acetylcholine (ACh)** during diagnostic tests. [1]*Fixed plaque obstruction*- This pathology defines **Stable Angina**, where chest pain is typically predictable and primarily brought on by physical **exertion** when myocardial oxygen demand exceeds fixed supply. [1]- Stable angina rarely occurs exclusively at rest upon waking and does not typically exhibit marked seasonal variation associated with **vasospasm** triggers like cold.*Subendocardial ischemia due to increased demand of myocardium*- Demand ischemia results from factors that increase myocardial workload (e.g., high heart rate, exercise), leading to supply-demand mismatch, which is minimized during rest/sleep. [1]- Prinzmetal's angina is a *supply* problem (vasospasm) causing acute, severe **transmural ischemia**, often presenting with transient **ST elevation** on ECG, differentiating it from typical subendocardial demand ischemia.*Increased sympathomimetic drive in morning hours*- While the natural circadian rhythm involves an increase in sympathetic tone upon waking, potentially triggering cardiac events, this does not describe the specific mechanism of the chest pain.- The symptoms described are most diagnostic of **Prinzmetal's angina**, a distinct disorder defined by localized arterial hyperreactivity rather than general sympathetic increase.
Question 1167: A patient after MI develops a broad QRS complex tachycardia. His BP is 120/85 mm Hg. ECG is given below. Best management?
- A. Nitroglycerin iv
- B. Amiodarone iv (Correct Answer)
- C. Metoprolol iv
- D. Labetalol iv
Explanation: ***Amiodarone iv*** - The ECG shows a **monomorphic wide-complex tachycardia** in a patient with a history of myocardial infarction, which is presumed to be **ventricular tachycardia (VT)** until proven otherwise. - For a **hemodynamically stable** patient (BP 120/85 mm Hg), intravenous antiarrhythmics like **amiodarone** or procainamide are the first-line treatment for terminating the arrhythmia. *Labetalol iv* - Intravenous beta-blockers like labetalol are generally avoided in the acute management of VT, especially in patients with structural heart disease. - Their **negative inotropic** effects can precipitate **hemodynamic collapse** and cardiogenic shock in a heart already compromised by a recent MI. *Metoprolol iv* - Similar to labetalol, metoprolol is a beta-blocker that is not recommended for the acute termination of VT. - While crucial for long-term management post-MI, its administration during an active VT episode can lead to severe **hypotension** and cardiac decompensation. *Nitroglycerin iv* - Nitroglycerin is a vasodilator used for ischemic chest pain and has no **antiarrhythmic properties** to terminate VT. - Its use could cause significant **vasodilation** and hypotension, potentially destabilizing the patient and converting a stable VT into an unstable one requiring immediate cardioversion.
Question 1168: A patient presents to the ER with central chest pain. He has a past medical history of heart disease. ECG is shown below. What is the diagnosis?
- A. Inferolateral MI
- B. Anterolateral MI (Correct Answer)
- C. Constrictive pericarditis
- D. Acute pericarditis
Explanation: ***Anterolateral MI*** - The ECG shows significant **ST-segment elevation** in the anterior leads (**V1-V4**) and the lateral leads (**I, aVL, V5, V6**), which is characteristic of an extensive anterolateral myocardial infarction. - This pattern typically indicates an occlusion of the proximal **Left Anterior Descending (LAD) artery**. The ST depression in the inferior leads (II, III, aVF) represents **reciprocal changes**. *Inferolateral MI* - An inferolateral MI would present with ST elevation in the **inferior leads (II, III, aVF)** and lateral leads (I, aVL, V5, V6). - This ECG shows **ST depression** in the inferior leads, which argues against an inferior wall infarction and instead supports an anterior MI as reciprocal changes. *Acute pericarditis* - Acute pericarditis typically causes **diffuse, concave ST elevation** across multiple territories, not localized to the anterolateral leads as seen here. - It is also often associated with **PR segment depression**, which is not a prominent feature in this ECG. The ST segments here are **convex (coved)**, which is more typical for MI. *Constrictive pericarditis* - This is a chronic condition and does not cause acute ST-segment elevation. Its ECG findings are usually non-specific. - Typical findings for constrictive pericarditis include **low-voltage QRS complexes** and generalized T-wave flattening or inversion, which are not present on this ECG.
Question 1169: A patient with a history of rheumatic fever presents with a loud S1 and a low-pitched mid-diastolic murmur at the apex (best heard with the patient in the left lateral position). What is the most likely diagnosis?
- A. Mitral Stenosis (MS) (Correct Answer)
- B. Tricuspid Stenosis (TS)
- C. Mitral Regurgitation (MR)
- D. Aortic Regurgitation (AR)
Explanation: ***Mitral Stenosis (MS)*** - The classic auscultatory findings include a **loud S1** (due to forceful closure of the stiff mitral valve) and a low-pitched, rumbling **mid-diastolic murmur** at the apex, which are pathognomonic for MS [3]. - A history of **rheumatic fever** is the most common cause of mitral stenosis worldwide. The murmur is best heard in the **left lateral decubitus position**, and an **opening snap (OS)** may be heard after S2 [1], [3]. *Tricuspid Stenosis (TS)* - TS produces a mid-diastolic murmur, but it is best heard at the **left lower sternal border**, not the apex [2]. - The murmur of TS characteristically **intensifies with inspiration** (Carvallo's sign), a feature not described in this patient. *Mitral Regurgitation (MR)* - MR causes a **holosystolic (pansystolic) murmur**, meaning it occurs throughout systole, not diastole. - In chronic MR, the S1 sound is typically **soft or absent**, not loud, due to incomplete closure of the mitral valve leaflets. *Aortic Regurgitation (AR)* - AR is characterized by a high-pitched, blowing, **early diastolic decrescendo murmur** best heard along the left sternal border [4]. - It is associated with signs of a wide pulse pressure, such as **bounding peripheral pulses** (Corrigan's pulse), not a loud S1 or a mid-diastolic murmur at the apex.
Question 1170: A 25-year-old female with a previous history of rheumatic fever. Examination shows a loud S1 and mid-diastolic murmur. Which of the following valvular heart diseases does she have?
- A. MS (Correct Answer)
- B. TS
- C. MR
- D. AR
Explanation: ***MS*** - The combination of a history of **rheumatic fever** (the most common cause of MS globally) and the specific auscultatory findings are highly diagnostic of **mitral stenosis** [1]. - A **loud S1** results from the abrupt closure of the stiffened, high-pressure mitral valve, and a **mid-diastolic murmur** is caused by turbulent flow across the stenotic valve during rapid ventricular filling [2], [3]. *TS* - Tricuspid Stenosis (TS) is a rare sequelae of rheumatic fever and typically presents with a mid-diastolic murmur that *increases* with **inspiration** (**Carvallo's sign**) [2]. - The murmur of TS is best heard at the **left sternal border** (tricuspid area) and is usually accompanied by prominent signs of systemic congestion (e.g., ascites). *MR* - **Mitral Regurgitation** produces a high-pitched, blowing **holosystolic murmur** that typically radiates to the axilla, not a mid-diastolic murmur. - A loud S1 is often *absent* in significant MR as the valve leaflets do not coapt properly; S1 is usually normal or soft. *AR* - **Aortic Regurgitation** is characterized by a high-pitched **diastolic decrescendo murmur** best heard along the left sternal border [4]. - AR is frequently associated with signs of increased stroke volume and wide pulse pressure, such as the **Water-hammer pulse**, none of which are characteristic of this presentation.
Practice by Chapter
Coronary Artery Disease and Angina
Practice Questions
Acute Coronary Syndromes
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Heart Failure
Practice Questions
Cardiac Arrhythmias
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Valvular Heart Diseases
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Cardiomyopathies
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Pericardial Diseases
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Congenital Heart Disease in Adults
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Hypertension and Hypertensive Emergencies
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Pulmonary Hypertension
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Non-invasive Cardiac Diagnostics
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Preventive Cardiology
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