Cardiology Practice Questions

Q: Wide QRS complex (≥ 0.12 seconds) can be seen in various conditions. Which of the following is least likely to present with a wide QRS complex?

Left Anterior Fascicular Block. ***Left Anterior Fascicular Block*** - While a **Left Anterior Fascicular Block (LAFB)** does affect ventricular depolarization, it typically causes a **left axis deviation** and only *slight widening* of the QRS complex, usually less than 0.12 seconds. - The delay in conduction is primarily through one of the fascicles of the left bundle branch, not the entire ventricular conduction system. *Hyperkalemia* - Severe **hyperkalemia** can significantly impair myocardial conduction, leading to a **diffuse slowing of ventricular depolarization**. - This results in a **widened QRS complex** as the potassium levels increase, along with peaked T waves and eventually sine wave patterns. *Wolf Parkinson White Syndrome* - **Wolff-Parkinson-White (WPW) syndrome** involves an **accessory pathway** that bypasses the AV node, leading to pre-excitation of the ventricles [1, 2]. - This abnormal conduction pathway results in a **short PR interval** and a **delta wave**, which combines with normal ventricular activation to produce a **wide QRS complex** [2]. *Ventricular Tachycardia* - **Ventricular tachycardia (VT)** originates in the ventricles, bypassing the normal His-Purkinje system [3]. - This abnormal ventricular activation sequence leads to a **markedly widened QRS complex** (typically > 0.12 seconds) due to slow, muscle-to-muscle conduction [3].

Q: Which of the following conditions is a known cause of Right Bundle Branch Block (RBBB)?

Cor pulmonale. ### Question Which of the following conditions is a known cause of Right Bundle Branch Block (RBBB)? ### Original Explanation ***Cor pulmonale*** - **Cor pulmonale** is **right ventricular hypertrophy** with or without dilation due to pulmonary hypertension, impacting the right ventricle's conduction system and causing **RBBB** [1]. - The increased pressure and strain on the right side of the heart can damage the right bundle branch, leading to a conduction delay visible as **RBBB** on an ECG [1]. *Normal aging process* - While the **normal aging process** can lead to some degenerative changes in the heart's conduction system, it more commonly causes **Left Anterior Fascicular Block** or **Left Bundle Branch Block (LBBB)**, rather than isolated RBBB. - Significant **RBBB** in an elderly individual often points to an underlying structural or physiological cause rather than mere aging. *Pulmonary embolism* - A **pulmonary embolism** can cause acute **right ventricular strain** and dilation, which can mimic **RBBB** or cause a transient RBBB pattern [1]. - However, **RBBB** is not a direct consequence of the physical obstruction but rather an effect of the resulting **acute pulmonary hypertension** and right heart strain [2]. *Myocardial infarction* - A **myocardial infarction** affecting the **septum** or the **right ventricle** can damage the right bundle branch, leading to **RBBB**. - However, the most classic ECG finding of a myocardial infarction is **ST-segment elevation** or **new Q waves**, with **RBBB** being a potential complication rather than a direct cause [3].

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].

Q: Low QRS voltage on ECG indicates ?

Pericardial effusion. ***Pericardial effusion*** - A significant **pericardial effusion** can lead to low QRS voltage on ECG because the fluid surrounding the heart acts as an electrical insulator, dampening the electrical signals [1]. - This dampening effect reduces the amplitude of the QRS complexes recorded on the electrocardiogram [1]. *Pulmonary embolism* - While pulmonary embolism can cause various ECG changes (e.g., **S1Q3T3 pattern**, right axis deviation), it typically does not directly cause low QRS voltage. - The primary hemodynamic impact is on the right side of the heart and does not involve fluid accumulation around the heart to dampen electrical signals. *Cor pulmonale* - **Cor pulmonale** is right ventricular hypertrophy secondary to lung disease; ECG usually shows signs of **right ventricular hypertrophy** (e.g., tall R waves in V1, right axis deviation). - This condition is associated with increased electrical activity in the right ventricle, generally leading to larger, not smaller, QRS complexes in relevant leads. *Infective endocarditis* - **Infective endocarditis** affects heart valves and can cause rhythm disturbances or conduction blocks due to myocardial involvement or abscess formation. - It does not directly affect the electrical conductivity of the heart in a way that would cause generalized low QRS voltage.

Q: The S2 heart sound is best appreciated in:

2nd right intercostal space. ***2nd right intercostal space*** - The **S2 heart sound** is produced primarily by the closure of the **aortic and pulmonic valves** [1]. - The **aortic component (A2)** is best heard at the **right upper sternal border** (2nd right intercostal space), where the aorta is closest to the chest wall [2]. *4th left intercostal space* - This area is typically associated with the **tricuspid valve area**, where tricuspid murmurs and S3/S4 sounds related to the right ventricle can be more prominent. - While heart sounds can be heard here, it is not the primary location for appreciating the S2 sound. *5th left intercostal space* - This is the **mitral area** or **apex**, where the apical impulse is felt and the S1 heart sound (mitral component) is best heard [2]. - The S2 sound is much less prominent here compared to the base of the heart. *3rd left intercostal space* - This is often referred to as **Erb's point**, where murmurs of both aortic and pulmonic origin can sometimes be heard. - While S2 can be heard here, the **2nd right intercostal space** is superior for primarily appreciating the aortic component of S2, and the 2nd left intercostal space for the pulmonic component [2].

Q: Which of the following arrhythmias is most commonly associated with alcohol binge in alcoholics?

Atrial fibrillation. ***Atrial fibrillation*** - **Atrial fibrillation** is the most common arrhythmia associated with alcohol binge, often referred to as **"holiday heart syndrome"** [1]. - Alcohol can trigger AF by affecting **autonomic tone**, causing **electrolyte imbalances**, and direct **myocardial toxicity**, leading to electrical instability in the atria. *Ventricular fibrillations* - **Ventricular fibrillation** is a life-threatening arrhythmia that leads to cardiac arrest and is typically associated with **acute myocardial infarction** or severe **structural heart disease**, not commonly alcohol binge alone [3]. - While alcohol can increase the risk of other cardiac events, VF is not the primary arrhythmia directly induced by an alcohol binge [3]. *Ventricular premature contractions* - **Ventricular premature contractions (VPCs)** are common and can be triggered by various factors including stress, caffeine, and alcohol, but they are generally benign and not the most commonly reported serious arrhythmia from alcohol binge. - While an increase in VPCs might occur, they do not carry the same clinical significance or prevalence as AF in the context of acute alcohol consumption. *Atrial flutter* - **Atrial flutter** is another atrial arrhythmia that can be seen in patients with structural heart disease or hypertension, and can be precipitated by alcohol [2]. - However, **atrial fibrillation** is far more prevalent in acute alcohol-induced arrhythmias, making it a more common association than atrial flutter [1].

Q: Treatment of asymptomatic bradycardia is

No treatment is required. **No treatment is required** - **Asymptomatic bradycardia** generally indicates that the heart rate, though slow, is sufficient to meet the body's metabolic demands. - Intervening in the absence of symptoms could be unnecessary and potentially introduce risks without clear benefit [2]. *Give atropine* - **Atropine** is typically used for **symptomatic bradycardia** (e.g., hypotension, altered mental status, chest pain) to increase heart rate by blocking parasympathetic action. - In an asymptomatic patient, its use is not indicated and could lead to side effects like tachycardia or urinary retention. *Isoprenaline* - **Isoprenaline** is a non-selective beta-agonist used to increase heart rate and contractility, often in severe bradycardia or heart block. - Like atropine, its use is reserved for **symptomatic bradycardia** or specific emergency situations, not for asymptomatic conditions. *Cardiac pacing* - **Cardiac pacing** (either temporary or permanent) is indicated for **symptomatic bradycardia** that is refractory to pharmacological treatment or for certain types of heart block [1]. - It is an invasive procedure and is not appropriate for a patient who is asymptomatic.

Q: What is the most common cause of sudden death in patients with sarcoidosis?

Arrhythmias. ***Arrhythmias*** - **Cardiac sarcoidosis** can lead to granulomatous infiltration of the myocardium, disrupting the **cardiac conduction system**. - This disruption can result in various **arrhythmias**, including **ventricular tachycardia** and **ventricular fibrillation**, which are frequent causes of sudden cardiac death [2]. *Pneumonia* - While sarcoidosis can affect the lungs, leading to **pulmonary fibrosis** and increased susceptibility to infection, **pneumonia** is not the most common cause of sudden death in these patients. - Death from pneumonia is typically due to **respiratory failure** which is often preceded by a period of illness rather than being sudden. *Cor pulmonale* - **Cor pulmonale** (right heart failure due to lung disease) can develop in advanced pulmonary sarcoidosis due to **pulmonary hypertension**. - While a serious complication, it generally leads to a more **gradual decline** in cardiac function rather than sudden death. *Liver failure* - **Hepatic involvement** in sarcoidosis is common, with granulomas found in the liver, but **liver failure** as a direct cause of sudden death is rare [1]. - Significant liver dysfunction usually progresses over time, leading to more chronic symptoms.

Q: What does a -30 to -90 degree axis deviation indicate?

Left Axis Deviation. ***Left Axis Deviation*** - A cardiac axis between **-30 and -90 degrees** is defined as **Left Axis Deviation (LAD)** [1]. - LAD is typically caused by conditions such as **left ventricular hypertrophy**, **inferior myocardial infarction**, or **left anterior fascicular block**. *Right Axis Deviation* - Right Axis Deviation generally refers to an axis between **+90 and +180 degrees**. - It is often associated with conditions like **right ventricular hypertrophy** or **left posterior fascicular block**. *Extreme Right Axis Deviation* - **Extreme Right Axis Deviation**, sometimes called "Northwest axis," indicates an axis between **-90 and -180 degrees**. - This is a rare finding, usually associated with severe conditions such as **ventricular tachycardia** or **pulmonary embolism**. *Normal Cardiac Axis* - A **normal cardiac axis** typically falls between **-30 and +90 degrees** [1]. - The given range of **-30 to -90 degrees** extends beyond the normal range, indicating an abnormal deviation.

Question 1

Wide QRS complex (≥ 0.12 seconds) can be seen in various conditions. Which of the following is least likely to present with a wide QRS complex?

Accepted Answer

Left Anterior Fascicular Block

Answer

Hyperkalemia

Answer

Wolf Parkinson White Syndrome

Answer

Ventricular Tachycardia

Question 2

Which of the following conditions is a known cause of Right Bundle Branch Block (RBBB)?

Accepted Answer

Cor pulmonale

Answer

Myocardial infarction

Answer

Normal aging process

Answer

Pulmonary embolism

Question 3

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 4

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

Question 5

Low QRS voltage on ECG indicates ?

Accepted Answer

Pericardial effusion

Answer

Pulmonary embolism

Answer

Cor pulmonale

Answer

Infective endocarditis

Question 6

The S2 heart sound is best appreciated in:

Accepted Answer

2nd right intercostal space

Answer

4th left intercostal space

Answer

5th left intercostal space

Answer

3rd left intercostal space

Question 7

Which of the following arrhythmias is most commonly associated with alcohol binge in alcoholics?

Accepted Answer

Atrial fibrillation

Answer

Ventricular fibrillations

Answer

Ventricular premature contractions

Answer

Atrial flutter

Question 8

Treatment of asymptomatic bradycardia is

Accepted Answer

No treatment is required

Answer

Give atropine

Answer

Isoprenaline

Answer

Cardiac pacing

Question 9

What is the most common cause of sudden death in patients with sarcoidosis?

Accepted Answer

Arrhythmias

Answer

Pneumonia

Answer

Cor pulmonale

Answer

Liver failure

Question 10

What does a -30 to -90 degree axis deviation indicate?

Accepted Answer

Left Axis Deviation

Answer

Right Axis Deviation

Answer

Normal Cardiac Axis

Answer

Extreme Right Axis Deviation

Cardiology — MCQs

Cardiology — MCQs

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