Cardiology Practice Questions

Q: A patient presents with chest pain and an ECG showing ST-segment elevation. After treatment, the ECG shows resolution of ST-segment changes, but the patient continues to have chest pain. What is the most likely diagnosis?

Takotsubo cardiomyopathy. ***Takotsubo cardiomyopathy*** - Characterized by **transient ventricular dysfunction** (often apical ballooning) mimicking a heart attack, usually triggered by severe emotional or physical stress. - **Resolution of ST-segment elevation** but persistent chest pain after initial presentation, especially if coronary angiography is normal, strongly suggests this diagnosis. *Acute myocardial infarction* - While initially presenting with **ST-segment elevation** and chest pain, resolution of ST-segment changes without corresponding clinical improvement or complete resolution of symptoms would be unusual without reperfusion, and persistent pain might indicate ongoing ischemia or complications [1], [2]. - The key difference here is the **spontaneous resolution of ST elevation** while pain persists, and the absence of clear coronary artery occlusion in Takotsubo. *Myocarditis* - **Myocarditis** can cause chest pain and ECG abnormalities, including ST-segment elevation, but the specific pattern of resolution of ST changes with persistent pain and the typical trigger of emotional stress are less characteristic. - Diagnosis often involves **cardiac MRI** showing inflammation and is not characterized by the quick resolution of acute ECG changes seen here. *Pericarditis* - Pericarditis typically presents with **pleuritic chest pain** that is relieved by leaning forward, and diffused ST-segment elevation (often PR depression) followed by T-wave inversions. - The **resolution of ST-segment changes** mentioned, especially in the context of an initial ST elevation that might mimic an MI, does not fit the typical evolutionary ECG changes of pericarditis.

Q: Which of the following features is NOT a characteristic of tetralogy of Fallot?

Atrial septal defect. ***Atrial septal defect*** - While other **cardiac anomalies** can coexist with Tetralogy of Fallot, an **atrial septal defect (ASD)** is not one of its four defining characteristics. - The classic description of Tetralogy of Fallot includes **pulmonary stenosis**, **right ventricular hypertrophy**, **overriding aorta**, and a **ventricular septal defect.** [1] *Ventricular septal defect* - A **large ventricular septal defect (VSD)** is one of the four essential components of Tetralogy of Fallot, allowing for unoxygenated blood to mix with oxygenated blood. [1] - The size of the **VSD** is typically large and unrestrictive, leading to pressure equalization between the ventricles. [1] *Right ventricular hypertrophy* - **Right ventricular hypertrophy** develops as a compensatory mechanism due to the increased resistance from the **pulmonary stenosis**, making the right ventricle work harder to pump blood. [1] - It is a direct consequence of the elevated pressure in the right ventricle, necessary to overcome the obstruction to pulmonary blood flow. *Pulmonary stenosis* - **Pulmonary stenosis**, or the narrowing of the pulmonary outflow tract, is a critical component that determines the severity of cyanosis in Tetralogy of Fallot. [1] - The degree of **right ventricular outflow tract obstruction** significantly impacts the amount of blood shunted across the VSD and into the aorta.

Q: Which of the following is not seen in patent ductus arteriosus?

Attenuated S1. ***Attenuated S1*** - A **patent ductus arteriosus (PDA)** typically presents with a loud **S1 sound** due to increased blood flow through the mitral and tricuspid valves. - An attenuated, or soft, S1 would suggest impaired ventricular filling or reduced ventricular contractility, which is not characteristic of PDA. *Left atrial hypertrophy* - In a PDA, blood shunts from the aorta to the pulmonary artery, leading to **increased pulmonary blood flow** and **pulmonary venous return to the left atrium** [1]. - This chronic volume overload causes **left atrial dilation** and subsequent hypertrophy as it works harder to pump excess blood into the left ventricle. *Left ventricular enlargement* - The increased pulmonary venous return from the PDA results in **volume overload** of the left ventricle [1]. - The left ventricle has to pump a larger volume of blood, leading to **left ventricular dilation** and hypertrophy over time [1]. *Continuous murmur* - The classic physical finding in PDA is a **continuous "machinery-like" murmur**, best heard at the upper left sternal border [1]. - This murmur is continuous because blood flows from the higher-pressure aorta into the lower-pressure pulmonary artery throughout both systole and diastole [1].

Q: Downhill esophageal varices develop as a result of obstruction of which vein?

Superior vena cava. ***Superior vena cava*** - Downhill esophageal varices are caused by obstruction of the **superior vena cava (SVC)**, leading to increased pressure in the venous drainage of the upper esophagus. - The collateral circulation needed to bypass the SVC obstruction involves veins that drain into the **azygos system**, which then communicates with the esophageal veins. *Portal vein* - Obstruction of the **portal vein** or portal hypertension typically leads to **uphill esophageal varices**, affecting the lower esophagus [1]. - These varices are part of the collateral circulation formed to decompress the portal system, often seen in conditions like **cirrhosis** [1]. *Hepatic vein* - Obstruction of the **hepatic veins** (e.g., Budd-Chiari syndrome) causes blood to back up into the liver, leading to **portal hypertension** and potentially uphill esophageal varices. - This condition primarily affects the liver and causes a distinct clinical picture of ascites, hepatomegaly, and abdominal pain, not directly downhill varices. *Inferior vena cava* - Obstruction of the **inferior vena cava (IVC)** primarily affects venous return from the lower body and the liver (if above the hepatic veins). - While it can indirectly affect portal pressure if liver drainage is compromised, it is not the direct cause of esophageal varices, especially not the downhill type, which involves the superior venous drainage.

Q: Which of the following is not a contraindication for percutaneous balloon mitral valvotomy?

Presence of pulmonary hypertension. Presence of pulmonary hypertension - The presence of **pulmonary hypertension** is typically an indication, not a contraindication, for percutaneous balloon mitral valvotomy, as reducing mitral stenosis can alleviate pulmonary pressures. [1] - Alleviating the **mitral valve obstruction** can improve forward flow and reduce back pressure on the pulmonary circulation. *Left atrial thrombus* - A **left atrial thrombus** is a contraindication as it poses a significant risk of systemic embolism during the procedure. [1] - Imaging, typically transesophageal echocardiography, is performed to rule out thrombosis before the procedure. *Severe mitral regurgitation* - **Severe mitral regurgitation** is a contraindication because the procedure aims to open the mitral valve, which could worsen an already problematic regurgitation. - In such cases, **surgical repair** or replacement is usually a more appropriate intervention. *Commissural calcification* - **Significant commissural calcification** is a contraindication as it hinders successful balloon inflation and increases the risk of complications such as leaflet tearing or inadequate valve opening. - The presence of calcification often indicates a less pliable valve that is unlikely to respond well to balloon dilatation.

Q: Episode of stable angina pectoris typically lasts for

2 - 5 mins. ***2 - 5 mins*** - Episodes of **stable angina pectoris** are typically brief, lasting between 2 and 5 minutes [1]. - The chest discomfort is usually relieved by **rest** or sublingual **nitroglycerin** [1]. *Less than 1 min* - Anginal episodes usually last longer than 1 minute; very brief chest pain is often not typical for angina. - This duration might suggest a different etiology, potentially **musculoskeletal pain** or **esophageal spasm**. *5 - 10 mins* - While a single episode can sometimes last up to 10 minutes, this duration is at the upper limit for typical stable angina. - If pain persists for this long or longer, it raises suspicion for **unstable angina** or **myocardial infarction** [1]. *> 10 mins* - Chest pain lasting longer than 10 minutes is usually concerning for **unstable angina** or an **acute myocardial infarction** [1]. - It requires urgent medical evaluation to rule out more serious cardiac events.

Q: Ejection click of pulmonary stenosis is better heard in

Inspiration. Inspiration - The **pulmonic ejection click** is associated with the opening of a **domed pulmonary valve** during systole [1]. - During **inspiration**, increased right ventricular filling causes more blood to be ejected, leading to earlier and louder opening of the stenotic pulmonary valve, making the click more prominent. Expiration - During **expiration**, venous return to the right side of the heart is reduced, decreasing right ventricular volume and making the pulmonic ejection click less noticeable or even absent. - This respiratory variation helps distinguish a pulmonic ejection click from an aortic ejection click, which does not vary with respiration [1]. Patient bending forward - **Bending forward** is a maneuver primarily used to accentuate **aortic regurgitation** murmurs, not to optimize the hearing of a pulmonic ejection click. - This position brings the heart closer to the chest wall, enhancing sounds originating from the left side of the heart. Patient lying in left lateral position - The **left lateral position** is commonly used to accentuate **mitral valve** sounds, such as the opening snap of mitral stenosis or the murmur of mitral regurgitation [1]. - This position does not specifically improve the audibility of a pulmonic ejection click.

Q: Levine sign is seen in

Acute Myocardial Infarction. ***Acute Myocardial Infarction*** - The **Levine sign** is a classic nonverbal gesture where a patient clenches their fist over the sternum, indicating **retrosternal chest pain** [1]. - This sign is highly suggestive of **ischemic chest pain**, often associated with an **acute myocardial infarction** [1]. *Pulmonary embolism* - Chest pain in pulmonary embolism is typically **pleuritic**, sharp, and localized, often worsened by breathing. - It does not usually present with the diffuse, constrictive quality expressed by the **Levine sign**. *Esophageal spasm* - Chest pain from esophageal spasm can mimic cardiac pain, but it is often described as a **squeezing or crushing sensation** behind the sternum and may be relieved by nitrates. - While it can be severe, it is less consistently associated with the **Levine sign** compared to myocardial infarction. *Aortic dissection* - The pain of aortic dissection is typically described as **sudden, severe, tearing, or ripping** and often radiates to the back. - It usually has a unique quality that is distinct from the constrictive pain signaled by the **Levine sign**.

Q: Which of the following is NOT a feature of aortic stenosis?

Pressure in the aorta is the same as in the left ventricle. ***Pressure in the aorta is the same as in the left ventricle*** - In **aortic stenosis**, there is a significant pressure gradient across the aortic valve during systole [2], meaning the **left ventricular pressure** is much higher than the **aortic pressure** to overcome the narrowed opening. - If the pressures were the same, it would indicate an unimpeded flow, suggesting the absence of significant stenosis. *Presence of ejection systolic murmur* - An **ejection systolic murmur** is a classic auscultatory finding in aortic stenosis, resulting from turbulent blood flow across the narrowed valve during systole [2]. [1] - This murmur is typically heard best at the **right upper sternal border** and radiates to the carotid arteries [2]. *Presence of pulsus tardus* - **Pulsus tardus** (or pulsus parvus et tardus) refers to a pulse that is weak (parvus) and delayed (tardus), which is characteristic of significant aortic stenosis [2]. - This occurs because the left ventricle ejects blood slowly and with reduced peak velocity into the aorta due to the **obstruction** at the valve. *Congestive heart failure* - **Congestive heart failure (CHF)** is a common complication of severe aortic stenosis. - The increased afterload on the left ventricle leads to **left ventricular hypertrophy** and eventual dysfunction, causing symptoms such as dyspnea, fatigue, and edema [1].

Q: Which of the following statements is true about Prinzmetal's angina?

May present at rest. ***May present at rest*** - Prinzmetal's angina, also known as **variant angina**, is characterized by episodes of chest pain that typically occur at **rest**, often in the early morning hours, which is a key distinguishing feature from stable angina. - This presentation at rest is due to transient **coronary artery spasm**, reducing blood flow to the myocardium. *Occurs due to atherosclerotic obstruction of coronary arteries* - While patients with Prinzmetal's angina may have some underlying atherosclerosis, the direct cause of the anginal episodes is **coronary artery spasm**, not fixed atherosclerotic obstruction. - **Stable angina** and **unstable angina** are primarily caused by atherosclerotic narrowing. *It typically occurs during exercise* - **Stable angina**, not Prinzmetal's angina, is the type of angina that typically occurs during **physical exertion** or emotional stress. - Prinzmetal's angina is notable for its occurrence at rest, often without clear precipitating factors, distinguishing it from exertional angina. *Beta-blockers are the first-line treatment for Prinzmetal's angina.* - **Calcium channel blockers** (e.g., diltiazem, verapamil, nifedipine) and **nitrates** are the first-line treatments for Prinzmetal's angina because they help relax the coronary arteries and prevent spasm. - **Beta-blockers** are generally avoided or used with caution in Prinzmetal's angina as they can potentially worsen coronary artery spasm.

Question 1

A patient presents with chest pain and an ECG showing ST-segment elevation. After treatment, the ECG shows resolution of ST-segment changes, but the patient continues to have chest pain. What is the most likely diagnosis?

Accepted Answer

Takotsubo cardiomyopathy

Answer

Acute myocardial infarction

Answer

Myocarditis

Answer

Pericarditis

Question 2

Which of the following features is NOT a characteristic of tetralogy of Fallot?

Accepted Answer

Atrial septal defect

Answer

Right ventricular hypertrophy

Answer

Pulmonary stenosis

Answer

Ventricular septal defect

Question 3

Which of the following is not seen in patent ductus arteriosus?

Accepted Answer

Attenuated S1

Answer

Left atrial hypertrophy

Answer

Left ventricular enlargement

Answer

Continuous murmur

Question 4

Downhill esophageal varices develop as a result of obstruction of which vein?

Accepted Answer

Superior vena cava

Answer

Portal vein

Answer

Hepatic vein

Answer

Inferior vena cava

Question 5

Which of the following is not a contraindication for percutaneous balloon mitral valvotomy?

Accepted Answer

Presence of pulmonary hypertension

Answer

Severe mitral regurgitation

Answer

Commissural calcification

Answer

Left atrial thrombus

Question 6

Episode of stable angina pectoris typically lasts for

Accepted Answer

2 - 5 mins

Answer

Less than 1 min

Answer

5 - 10 mins

Answer

> 10 mins

Question 7

Ejection click of pulmonary stenosis is better heard in

Accepted Answer

Inspiration

Answer

Patient bending forward

Answer

Patient lying in left lateral position

Answer

Expiration

Question 8

Levine sign is seen in

Accepted Answer

Acute Myocardial Infarction

Answer

Esophageal spasm

Answer

Aortic dissection

Answer

Pulmonary embolism

Question 9

Which of the following is NOT a feature of aortic stenosis?

Accepted Answer

Pressure in the aorta is the same as in the left ventricle

Answer

Presence of pulsus tardus

Answer

Presence of ejection systolic murmur

Answer

Congestive heart failure

Question 10

Which of the following statements is true about Prinzmetal's angina?

Accepted Answer

May present at rest

Answer

Occurs due to atherosclerotic obstruction of coronary arteries

Answer

It typically occurs during exercise

Answer

Beta-blockers are the first-line treatment for Prinzmetal's angina.

Cardiology — MCQs

Cardiology — MCQs

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