Cardiology — MCQs
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Which of the following drugs reduces mortality in a patient with heart failure?
A patient presents with dyspnea and distended neck veins that increase on inspiration. There is no murmur. What is the diagnosis?
A 73 year old male smoker with a past history of coronary artery disease presents with blackening of the toes. An image of the foot is shown below. What is the most likely diagnosis?
A 60-year-old male presents with claudication and blackening of the toes. An image of the foot is shown below. What is the most likely diagnosis? 
A large 'V' wave on jugular venous pulse (JVP) examination is characteristic of:
A 62-year-old male presents with sudden onset of shortness of breath and bilateral pedal edema. He is compliant with antihypertensive medications. Echocardiography reveals ejection fraction of 60 %, concentric left ventricular hypertrophy, left atrial enlargement, and grade 2 diastolic dysfunction. What is the most appropriate next step to improve his condition?
Which of the following is not a symptom of cardiac failure?
Mitral stenosis murmur corresponds to which wave of ECG?
A 58-year-old male presents to a PHC for a routine check-up. His blood pressure readings on two separate occasions are 148 / 90 mmHg and 152 / 96 mmHg. He is asymptomatic and has no known comorbidities. What is the most appropriate next step in management according to current hypertension guidelines?
A patient presents with palpitations and an irregularly irregular pulse. He presents within 2 hours of symptom onset, and has no history of diabetes or other comorbidities. What is the most appropriate initial management?
Cardiology Indian Medical PG Practice Questions and MCQs
Question 1181: Which of the following drugs reduces mortality in a patient with heart failure?
- A. Prazosin
- B. Torsemide
- C. Furosemide
- D. Metoprolol (Correct Answer)
Explanation: ***Correct: Metoprolol*** - *Beta-blockers* like **Metoprolol succinate** (extended-release form) reduce mortality in patients with **HFrEF** (Heart Failure with reduced Ejection Fraction) by blocking the deleterious effects of chronic sympathetic nervous system activation on the myocardium [1]. - These drugs prevent ventricular remodeling, reduce **sudden cardiac death** by lowering heart rate and improving oxygen demand/supply balance, and are cornerstone therapies alongside **ACE inhibitors/ARBs/ARNI** [1]. *Incorrect: Furosemide* - Furosemide is a **loop diuretic** used primarily for **symptom relief** (reducing edema, dyspnea) by promoting diuresis and natriuresis to manage volume overload. - It does not modify the underlying disease progression or cardiac remodeling and, thus, has **no demonstrated mortality benefit** in heart failure trials. *Incorrect: Prazosin* - Prazosin is an **alpha-1 adrenergic blocker** used primarily as a vasodilator or for hypertension, but it has not shown benefit and may even increase adverse events in long-term heart failure management. - Unlike approved vasodilator therapies (like hydralazine/nitrate combination in certain populations), Prazosin is **not recommended** for chronic HF therapy due to lack of mortality data and potential for **orthostatic hypotension**. *Incorrect: Torsemide* - Torsemide is a **high-ceiling loop diuretic** similar to Furosemide, typically used to manage symptoms of congestion and fluid retention in heart failure patients. - While some studies suggest better bioavailability than Furosemide, it ultimately functions as a diuretic and **does not confer a mortality benefit** in heart failure.
Question 1182: A patient presents with dyspnea and distended neck veins that increase on inspiration. There is no murmur. What is the diagnosis?
- A. Pulmonary arterial hypertension
- B. Tricuspid stenosis
- C. Constrictive pericarditis (Correct Answer)
- D. Aortic regurgitation
Explanation: ***Constrictive pericarditis***- The combination of dyspnea, distended neck veins, and the increase of neck vein distension on inspiration (**Kussmaul sign**) is highly suggestive of constrictive physiology, such as **constrictive pericarditis** [2].- This condition involves a rigid pericardium impairing diastolic filling, leading to elevated right atrial pressure and fixed cardiac volume, hence the characteristic **Kussmaul sign** [2].*Aortic regurgitation*- Typically presents with symptoms of left-sided heart failure (e.g., paroxysmal nocturnal dyspnea) and is characterized by a prominent **diastolic decrescendo murmur** [3].- Peripheral signs usually include **wide pulse pressure** and a bounding pulse (**water-hammer pulse**), none of which explain the Kussmaul sign [3].*Tricuspid stenosis*- This condition would cause right heart failure symptoms (JVD) but is always associated with a **diastolic rumbling murmur** best heard at the left sternal border or xiphoid area.- While **Kussmaul sign** can sometimes be seen in severe tricuspid stenosis, the primary feature is the presence of the characteristic murmur, which is noted as absent here.*Pulmonary arterial hypertension*- This condition causes right-sided heart failure (leading to JVD) but lacks the mechanical restriction of filling necessary to reliably produce the specific **Kussmaul sign** [1].- It is often associated with signs of secondary **tricuspid regurgitation** (a holosystolic murmur) due to right ventricular dilation [1].
Question 1183: A 73 year old male smoker with a past history of coronary artery disease presents with blackening of the toes. An image of the foot is shown below. What is the most likely diagnosis?
- A. Giant cell arteritis
- B. Buerger's disease
- C. Atherosclerosis (Correct Answer)
- D. Raynaud's disease
Explanation: ***Atherosclerosis*** - The patient's advanced age (73), history of **smoking**, and **coronary artery disease** are all major risk factors for atherosclerosis, the most common cause of peripheral arterial disease (PAD). - The blackening of the toes is indicative of **dry gangrene**, a form of tissue necrosis resulting from severe, chronic ischemia due to atherosclerotic occlusion of the arteries supplying the foot. *Buerger's disease* - This condition, also known as **thromboangiitis obliterans**, is a non-atherosclerotic vasculitis that typically affects **young male smokers**, usually under the age of 45. - The patient's advanced age makes Buerger's disease a much less likely diagnosis compared to atherosclerosis. *Raynaud's disease* - Raynaud's disease is characterized by episodic **vasospasm** of digital arteries, usually triggered by cold or stress, leading to distinct color changes (white, blue, and red), which is not the primary presentation here. - While severe secondary Raynaud's phenomenon can lead to gangrene, it is not the most probable cause in an elderly patient with multiple risk factors for atherosclerosis. *Giant cell arteritis* - This is a **large-vessel vasculitis** that typically affects patients over 50 and presents with symptoms like headache, jaw claudication, and visual disturbances. - While it can cause limb claudication, isolated digital gangrene is a very uncommon manifestation, and the patient's presentation is classic for atherosclerotic PAD.
Question 1184: A 60-year-old male presents with claudication and blackening of the toes. An image of the foot is shown below. What is the most likely diagnosis? 
- A. Buerger's disease
- B. Atherosclerosis (Correct Answer)
- C. Raynaud's disease
- D. Giant cell arteritis
Explanation: ***Atherosclerosis*** - Atherosclerosis is the most common cause of **peripheral artery disease (PAD)** in patients over 50, leading to stenosis of arteries and causing symptoms like **claudication** (pain on exertion). - Severe, progressive disease results in **critical limb ischemia**, characterized by insufficient blood flow to meet metabolic demands at rest, which can lead to tissue necrosis and **gangrene** (blackening of the toes) as seen in the image. *Buerger's disease* - This condition, also known as **thromboangiitis obliterans**, is a non-atherosclerotic inflammatory vasculitis that typically affects **young male smokers** (usually under 45 years old). - It characteristically involves small-to-medium-sized arteries and veins and is often associated with superficial thrombophlebitis, which is not typical for this patient's demographic. *Raynaud's disease* - This is a functional vascular disorder characterized by episodic **vasospasm** of digital arteries, usually triggered by cold or stress, leading to well-demarcated color changes (white, blue, and red). - It does not cause claudication, which is a symptom of fixed arterial obstruction, and rarely results in the extensive, progressive gangrene seen in this case. *Giant cell arteritis* - This is a vasculitis of large and medium-sized arteries, primarily affecting branches of the **carotid artery** (e.g., temporal artery), leading to headache, jaw claudication, and visual loss. - While it can involve limb arteries, isolated severe lower limb ischemia with gangrene is an uncommon presentation; **atherosclerosis** is a far more frequent cause in this age group.
Question 1185: A large 'V' wave on jugular venous pulse (JVP) examination is characteristic of:
- A. Tricuspid regurgitation (Correct Answer)
- B. Aortic regurgitation
- C. Tricuspid stenosis
- D. Atrial fibrillation
Explanation: ***Tricuspid regurgitation*** - A large **'V' wave** (ventricular systole) on JVP signifies increased pressure in the right atrium due to substantial **regurgitant flow** back from the right ventricle against a closed tricuspid valve.- This results in the rapid filling and distention of the right atrium during ventricular systole, often accompanied by the blunting or absence of the normal **'x' descent** (the 'x' descent is replaced by a systolic wave).*Aortic regurgitation* - Aortic regurgitation (AR) primarily affects the **left heart** and does not directly alter the established right heart pressure waveforms seen in the JVP [1].- Clinical signs of AR include a wide **pulse pressure**, **water-hammer pulse**, and diastolic murmur, but not specific waveform changes on JVP [3].*Tricuspid stenosis*- **Tricuspid stenosis** causes resistance to flow from the RA to the RV, leading to an exaggerated pressure rise during RA contraction, resulting in a prominent (tall) **'a' wave** [2].- The **'y' descent** is typically slow or attenuated because the rapid filling phase of the RV is impaired by the stenotic valve [2].*Atrial fibrillation* - In **atrial fibrillation (AFib)**, the uncoordinated atrial activity eliminates the mechanical contraction of the atria, causing the JVP tracing to lose the distinct **'a' wave**.- The ventricular rate is typically rapid and irregular, making JVP waveforms irregular, but it does not specifically cause a massive 'V' wave.
Question 1186: A 62-year-old male presents with sudden onset of shortness of breath and bilateral pedal edema. He is compliant with antihypertensive medications. Echocardiography reveals ejection fraction of 60 %, concentric left ventricular hypertrophy, left atrial enlargement, and grade 2 diastolic dysfunction. What is the most appropriate next step to improve his condition?
- A. Start digoxin to enhance myocardial contractility
- B. Perform coronary angiography to rule out ischemic cardiomyopathy
- C. Initiate loop diuretics and SGLT2 inhibitors for management of HFpEF (Correct Answer)
- D. Initiate ivabradine to reduce heart rate and improve diastolic filling
Explanation: ***Initiate loop diuretics and SGLT2 inhibitors for management of HFpEF*** - The clinical picture (sudden onset dyspnea, bilateral **pedal edema**) and echocardiography findings (EF $\ge$ 50%, **concentric LVH**, LA enlargement, **diastolic dysfunction**) define **Heart Failure with Preserved Ejection Fraction (HFpEF)** [3]. Echocardiography is essential to determine the aetiology and identify patients who will benefit from targeted therapy [1]. - **Loop diuretics** are essential for symptom relief (edema, congestion) [2], and **SGLT2 inhibitors** (e.g., empagliflozin, dapagliflozin) are recommended as foundational therapy for HFpEF, improving outcomes regardless of diabetes status. ***Perform coronary angiography to rule out ischemic cardiomyopathy*** - While coronary artery disease is a common cause of heart failure [3], the patient's EF is preserved (60%), making **ischemic cardiomyopathy** less likely as the primary cause of his acute presentation. - Coronary angiography is an invasive procedure and is not the immediate, most appropriate step for managing acute HF symptoms related to **volume overload** and diastolic dysfunction [4]. ***Start digoxin to enhance myocardial contractility*** - **Digoxin** is primarily used in **Heart Failure with Reduced Ejection Fraction (HFrEF)** (EF < 40%) to improve contractility and for rate control in atrial fibrillation. - Since the patient has preserved EF (60%), digoxin would offer little benefit and may increase the risk of toxicity without addressing the underlying **diastolic impairment**. ***Initiate ivabradine to reduce heart rate and improve diastolic filling*** - **Ivabradine** is indicated primarily in **HFrEF** (EF $\le$ 35%) for patients who are in sinus rhythm with a resting heart rate $\ge$ 70 bpm and are unable to tolerate or are maximized on beta-blockers. - It is not a standard or appropriate treatment for acutely decompensated HFpEF, where volume management and **SGLT2 inhibition** are key priorities.
Question 1187: Which of the following is not a symptom of cardiac failure?
- A. Right hypochondriac pain (Correct Answer)
- B. Non-pulsatile elevation of JVP
- C. Orthopnea
- D. Paroxysmal nocturnal dyspnea
Explanation: Rationale: The question asks for a finding that is *not* a symptom of cardiac failure. Most symptoms relate to pulmonary congestion (left failure) or systemic venous congestion (right failure). ***Right hypochondriac pain*** - Right hypochondriac pain is a common symptom of **right-sided heart failure (RHF)**, caused by **hepatic congestion** (congestive hepatomegaly) and stretch of the Glisson’s capsule. - Since the question asks for a symptom that is *not* a symptom of cardiac failure, and RHP *is* a symptom (due to passive hepatic congestion), this is the common expected answer, or there is an issue with the question phrasing or options provided. ***Non-pulsatile elevation of JVP*** - **Elevated JVP (Jugular Venous Pressure)** is a cardinal sign of **right-sided heart failure** due to increased central venous pressure. [3] - However, JVP is typically **pulsatile**, reflecting the cardiac cycle. A **non-pulsatile JVP** often indicates a completely obstructed venous filling, such as from superior vena cava (SVC) syndrome, pericardial effusion (though still sometimes pulsatile), or severe tricuspid regurgitation (if the pulsations are too massive and obscured). Thus, a strictly non-pulsatile JVP is less characteristic of typical cardiac failure. ***Orthopnea*** - This is breathlessness when lying flat, a classic symptom of **left-sided heart failure** due to pulmonary venous congestion that worsens in the supine position. [1], [2] - It is relieved by assuming an upright position (sitting or standing). ***Paroxysmal nocturnal dyspnea*** - PND is sudden, severe shortness of breath that wakes the patient from sleep, typically 1–2 hours after falling asleep, also characteristic of severe **left-sided heart failure**. [1] - It is caused by delayed resorption of peripheral edema and increased venous return while supine, leading to acute pulmonary congestion.
Question 1188: Mitral stenosis murmur corresponds to which wave of ECG?
- A. QRS complex
- B. ST segment
- C. P wave (Correct Answer)
- D. T wave
Explanation: ***P wave*** - The **P wave** on the ECG represents **atrial depolarization** and precedes atrial contraction (atrial systole) [3]. - In **mitral stenosis (MS)**, the characteristic presystolic accentuation (a later component of the diastolic murmur) is caused by the force of atrial contraction just prior to the QRS complex, correlating with the P wave [4]. ***QRS complex*** - The **QRS complex** represents **ventricular depolarization** and precedes ventricular contraction (ventricular systole) [3]. - The mitral stenosis murmur is a **diastolic murmur**; it occurs after the T wave and ends before the QRS complex (or is accentuated just before it by atrial kick) [1], [4]. ***T wave*** - The **T wave** represents **ventricular repolarization** [3]. - The T wave marks the end of systole; the mitral stenosis murmur begins *after* the T wave, during the period of isovolumetric relaxation and subsequent rapid ventricular filling [2]. ***ST segment*** - The **ST segment** represents the period between ventricular depolarization and repolarization (plateau phase of the action potential). - This segment is part of systole, whereas the mitral stenosis murmur is strictly a **diastolic event** [1], [4].
Question 1189: A 58-year-old male presents to a PHC for a routine check-up. His blood pressure readings on two separate occasions are 148 / 90 mmHg and 152 / 96 mmHg. He is asymptomatic and has no known comorbidities. What is the most appropriate next step in management according to current hypertension guidelines?
- A. Initiate treatment only if BP exceeds 160 / 100 mmHg
- B. Start the patient on IV anti-hypertensive drugs
- C. Refer to a higher center for further evaluation
- D. Start Amlodipine 5 mg once daily and advise follow-up after a month (Correct Answer)
Explanation: Amlodipine 5 mg once daily and advise follow-up after a month - The patient's mean blood pressure (148/90 mmHg and 152/96 mmHg) falls into Stage 1 Hypertension (Systolic BP 140–159 mmHg or Diastolic BP 90–99 mmHg) in a low-risk 58-year-old without comorbidities. - For Stage 1 hypertension in standard-risk patients, current guidelines (e.g., ESC, JNC) recommend initiating pharmacological treatment, usually with a low-dose calcium channel blocker (like Amlodipine) or an ACE inhibitor/ARB, alongside lifestyle modifications [1]. Initiate treatment only if BP exceeds 160 / 100 mmHg - This threshold (160/100 mmHg) corresponds to Stage 2 Hypertension, where immediate drug treatment is mandatory for all patients, but treatment is also required sooner for Stage 1 in most individuals. - Delaying treatment ignores the current diagnosis of Stage 1 Hypertension and the risk associated with blood pressure starting at 140/90 mmHg [3]. Refer to a higher center for further evaluation - Referral is generally reserved for cases of resistant hypertension (BP remains high despite three drugs), secondary hypertension suspicion, or hypertensive emergencies. - This patient has uncomplicated Stage 1 Hypertension, which is appropriate for management at the Primary Healthcare Center (PHC) level. Start the patient on IV anti-hypertensive drugs - Intravenous (IV) anti-hypertensive drugs are strictly reserved for Hypertensive Emergency, defined by severely elevated BP (typically >180/120 mmHg) with evidence of acute target-organ damage [2]. - This patient is asymptomatic and only has Stage 1 hypertension; hence, oral therapy is the appropriate route of administration [2].
Question 1190: A patient presents with palpitations and an irregularly irregular pulse. He presents within 2 hours of symptom onset, and has no history of diabetes or other comorbidities. What is the most appropriate initial management?
- A. Control ventricular rate with verapamil
- B. TEE for starting anticoagulation
- C. Wait and watch
- D. Cardioversion (Correct Answer)
Explanation: ***Cardioversion*** - Since the patient presented within **<12 hours** of symptom onset (paroxysmal AF) and is hemodynamically stable, particularly without comorbidities, urgent rhythm control via **cardioversion (electrical or pharmacological)** is the optimal management to restore sinus rhythm [1]. - The very early presentation (within 2 hours) and the absence of significant comorbidities suggest a good chance for maintenance of sinus rhythm without immediate concern for complex thrombus formation. *TEE for starting anticoagulation* - **Transesophageal echocardiography (TEE)** is performed to rule out left atrial appendage thrombus before cardioversion if the duration of AF is **unknown or >48 hours**, or if anticoagulation has been inadequate (less than 3 weeks). - In this case, since the onset is clearly <48 hours and the patient is low risk without comorbidities, we prioritize immediate rhythm control over a mandatory TEE. *Control ventricular rate with verapamil* - **Rate control** (e.g., using calcium channel blockers like Verapamil or beta-blockers) is the primary goal for patients with **chronic** or **permanent** atrial fibrillation, or for those whose symptoms started **>48 hours** ago. - For new-onset AF with a short duration, **rhythm control** (cardioversion) is preferred [1]. *Wait and watch* - **Wait and watch** is inappropriate as **atrial fibrillation (AF)** is associated with a high risk of systemic embolization and stroke, necessitating prompt management (either rhythm or rate control). - Immediate intervention is required to prevent complications and potentially restore sinus rhythm, especially given the very early presentation.
Practice by Chapter
Coronary Artery Disease and Angina
Practice Questions
Acute Coronary Syndromes
Practice Questions
Heart Failure
Practice Questions
Cardiac Arrhythmias
Practice Questions
Valvular Heart Diseases
Practice Questions
Cardiomyopathies
Practice Questions
Pericardial Diseases
Practice Questions
Congenital Heart Disease in Adults
Practice Questions
Hypertension and Hypertensive Emergencies
Practice Questions
Pulmonary Hypertension
Practice Questions
Non-invasive Cardiac Diagnostics
Practice Questions
Preventive Cardiology
Practice Questions
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