Cardiology Practice Questions

Q: HOCM is common in which age group?

20 - 40 years. ***20 - 40 years*** - **Hypertrophic obstructive cardiomyopathy (HOCM)** is most commonly diagnosed in young to middle-aged adults, often presenting with symptoms during this age range [1]. - While it is a genetic condition present from birth, symptoms and diagnosis frequently occur in individuals who are **20 to 40 years old** [1]. *10 - 30 years* - While HOCM can manifest in adolescence, the peak incidence and symptomatic presentation typically extend into the 30s, making this range too narrow. - Many individuals in this group might be diagnosed during routine screenings or due to family history, but active symptom presentation often continues beyond 30 [1]. *30 - 50 years* - This age group is partially correct, but the onset often begins earlier, in the 20s. - Significant clinical manifestations and diagnoses are often made before the age of 30, making the 20-40 range more accurate for typical presentation. *40 - 60 years* - Although HOCM can persist and cause problems in older age, initial diagnoses and symptom onset are less common in this age group compared to younger adults [1]. - Patients diagnosed in this range often represent later presentations or milder forms that become symptomatic with aging [1].

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 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.

Q: Prolonged QT interval is seen in all of the following except

Hypernatremia. ***Hypernatremia*** - **Hypernatremia** does not typically cause a prolonged QT interval; instead, it tends to cause **shortening of the QT interval** due to its effect on cardiomyocyte repolarization. - The primary cardiac effects of hypernatremia involve alterations in **myocardial contractility** and **arrhythmia risk**, but not QT prolongation. *Hypokalemia* - **Hypokalemia** leads to changes in myocardial repolarization, causing **QT prolongation** which increases the risk of **Torsades de Pointes** [1], [2]. - This occurs because low potassium levels affect the outward potassium currents, extending the action potential duration. *Hypocalcemia* - **Hypocalcemia** prolongs the **QT interval** by extending the ST segment duration without significantly affecting the T wave morphology directly. - Reduced extracellular calcium levels interfere with the voltage-gated calcium channels, impacting the plateau phase of the cardiac action potential. *Use of macrolide antibiotics* - Many **macrolide antibiotics**, such as **azithromycin** and **erythromycin**, are known to inhibit cardiac potassium channels (specifically **IKr current**), thereby prolonging the QT interval [2]. - This effect can lead to a significant risk of **ventricular arrhythmias**, including **Torsades de Pointes** [2], [3].

Q: What is the PRIMARY complication that requires lifelong management in patients with mechanical prosthetic heart valves?

Thromboembolism. ***Thromboembolism*** - Mechanical prosthetic heart valves are inherently **thrombogenic** due to non-endothelialized surfaces that interact with blood components, necessitating lifelong **anticoagulation** to prevent clot formation [2]. - Clots can form on the valve and embolize, leading to serious complications such as **stroke** or **peripheral arterial occlusion** [1]. *Immediate valve failure* - While possible, **immediate valve failure** is a rare event typically related to surgical error or a manufacturing defect and is not a primary, ongoing management concern. - The durability of modern mechanical valves is excellent, so failure generally occurs over a long period, if at all, due to structural degradation or infection, rather than immediately post-op. *Acute myocardial infarction* - **Acute myocardial infarction** is primarily caused by **coronary artery disease** and is not a direct complication of the prosthetic heart valve itself. - While valve surgery can be associated with cardiac complications, MI is not a unique, lifelong management issue specifically attributable to the presence of a mechanical valve. *Pulmonary edema* - **Pulmonary edema** can occur in the setting of heart failure due to severe valve dysfunction or other cardiac issues, but it is not a direct or primary complication of the mechanical valve itself requiring lifelong management unique to the valve. - Effective valve function, whether native or prosthetic, is aimed at *preventing* pulmonary edema, not causing it.

Q: 38 yr old patient with high risk of coronary artery disease and hypertension, which of the following antihypertensive drugs will be suitable as a first line treatment for this patient?

ACE inhibitors. ### ACE inhibitors - **ACE inhibitors** are particularly suitable as first-line treatment for patients with hypertension and a high risk of **coronary artery disease (CAD)** because they have proven benefits in **cardiovascular protection** and **mortality reduction** [1]. - They improve **endothelial function** and can prevent **cardiac remodeling**, which is crucial in managing high-risk cardiovascular patients [4]. ### Calcium channel blockers - While effective for hypertension, **calcium channel blockers** do not offer the same level of **cardioprotection** in high-risk CAD patients as ACE inhibitors [1]. - They primarily act as **vasodilators** but lack the direct benefits on cardiac remodeling and atherosclerosis progression seen with ACE inhibitors. ### Beta-adrenergic blockers - **Beta-blockers** are generally not recommended as first-line monotherapy for essential hypertension unless there are specific compelling indications like **post-myocardial infarction** or **heart failure** [5]. - Their routine use as initial therapy for uncomplicated hypertension, especially in high-risk CAD patients without a recent event, is less favored compared to ACE inhibitors. ### Diuretics - **Diuretics**, particularly **thiazide diuretics**, are effective in lowering blood pressure and are often used, especially in elderly patients or those with salt sensitivity [3]. - However, for patients with high CAD risk, ACE inhibitors generally provide superior **cardiovascular benefit** beyond just blood pressure reduction, including preventing adverse cardiac events [2].

Q: What is commonly referred to as the widow's artery in myocardial infarction?

Left anterior descending artery. ***Left anterior descending artery*** - The **left anterior descending (LAD) artery** is often called the "widow maker" due to its critical role in supplying blood to a large area of the left ventricle, which is the heart's main pumping chamber [1]. - An **occlusion** in the LAD artery can lead to extensive damage, significantly increasing the risk of sudden cardiac death and making it a particularly dangerous site for a **myocardial infarction**. *Right coronary artery* - The **right coronary artery (RCA)** primarily supplies the **right ventricle**, the inferior wall of the left ventricle, and the SA/AV nodes. - While an RCA occlusion can cause a myocardial infarction, it is generally associated with a **better prognosis** and less extensive damage compared to an LAD occlusion. *Posterior interventricular artery* - The **posterior interventricular artery (PDA)**, also known as the posterior descending artery, typically branches off the RCA (in 85% of individuals) or the circumflex artery (in 15%) [2]. - It supplies the **diaphragmatic surface** of both ventricles and the posterior interventricular septum, but its occlusion is generally less critical than the LAD. *Left circumflex artery* - The **left circumflex artery (LCX)** supplies the lateral and posterior walls of the left ventricle [2]. - Although an LCX occlusion can lead to a significant myocardial infarction, it usually involves a **smaller territory** and is not as acutely life-threatening as an LAD occlusion.

Q: Which of the following statements about continuous murmurs is incorrect?

Seen with coarctation of aorta. ***Seen with coarctation of aorta*** - While coarctation of the aorta can produce a murmur, it is typically a **systolic ejection murmur**, not a continuous murmur [3]. - A continuous murmur implies flow throughout both systole and diastole, which is not characteristic of the pressure gradient across a coarctation. *Peaks at S2* - Continuous murmurs indeed often **peak around the second heart sound (S2)** [1] because the pressure gradient driving the flow is usually maximal during this period. - This peak intensity at S2 helps differentiate them from other types of murmurs. *Heard both in systole and diastole* - By definition, a continuous murmur is heard throughout **both systole and diastole**, without a clear break [2]. - This characteristic indicates a persistent pressure gradient allowing blood flow across a defect or vessel throughout the cardiac cycle. *Increase on squatting* - Squatting increases **venous return** and **systemic vascular resistance**, which generally intensifies most murmurs by increasing cardiac output and pressure gradients. - This maneuver is often used to assess the nature and severity of various cardiac murmurs [3], including continuous ones.

Q: Low QRS voltage on ECG with left ventricular hypertrophy on Echocardiography suggests a diagnosis of:

Cardiac Amyloidosis. ***Cardiac Amyloidosis*** - **Low QRS voltage** on ECG despite echocardiographic evidence of **left ventricular hypertrophy** is a classic paradox seen in cardiac amyloidosis. - Amyloid deposits infiltrate the myocardium, increasing wall thickness but **reducing electrical activity transmission**. *Cor pulmonale* - Cor pulmonale involves **right ventricular hypertrophy** due to pulmonary hypertension, not primarily left ventricular hypertrophy. - While it can cause changes in ECG findings, the combination of low QRS voltage with LVH is not characteristic. *Infective endocarditis* - Infective endocarditis primarily affects heart valves and can cause vegetations, but it does not typically lead to **left ventricular hypertrophy** or **low QRS voltage** on ECG. - ECG findings in endocarditis are often related to conduction abnormalities or ischemia if embolization occurs. *Pericardial effusion* - A significant pericardial effusion can cause **low QRS voltage** on ECG due to the dampening effect of fluid around the heart [1]. - However, it does not typically cause **left ventricular hypertrophy**; rather, it can be associated with signs of tamponade or inflammation [1].

Question 1

HOCM is common in which age group?

Accepted Answer

20 - 40 years

Answer

10 - 30 years

Answer

30 - 50 years

Answer

40 - 60 years

Question 2

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 3

Levine sign is seen in

Accepted Answer

Acute Myocardial Infarction

Answer

Esophageal spasm

Answer

Aortic dissection

Answer

Pulmonary embolism

Question 4

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.

Question 5

Prolonged QT interval is seen in all of the following except

Accepted Answer

Hypernatremia

Answer

Hypokalemia

Answer

Hypocalcemia

Answer

Use of macrolide antibiotics

Question 6

What is the PRIMARY complication that requires lifelong management in patients with mechanical prosthetic heart valves?

Accepted Answer

Thromboembolism

Answer

Immediate valve failure

Answer

Pulmonary edema

Answer

Acute myocardial infarction

Question 7

38 yr old patient with high risk of coronary artery disease and hypertension, which of the following antihypertensive drugs will be suitable as a first line treatment for this patient?

Accepted Answer

ACE inhibitors

Answer

Calcium channel blockers

Answer

Beta-adrenergic blockers

Answer

Diuretics

Question 8

What is commonly referred to as the widow's artery in myocardial infarction?

Accepted Answer

Left anterior descending artery

Answer

Right coronary artery

Answer

Posterior interventricular artery

Answer

Left circumflex artery

Question 9

Which of the following statements about continuous murmurs is incorrect?

Accepted Answer

Seen with coarctation of aorta

Answer

Heard both in systole and diastole

Answer

Peaks at S2

Answer

Increase on squatting

Question 10

Low QRS voltage on ECG with left ventricular hypertrophy on Echocardiography suggests a diagnosis of:

Accepted Answer

Cardiac Amyloidosis

Answer

Infective endocarditis

Answer

Cor pulmonale

Answer

Pericardial effusion

Cardiology — MCQs

Cardiology — MCQs

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