Cardiology Practice Questions

Q: What is the most appropriate immediate management for a hemodynamically unstable patient with supraventricular tachycardia (SVT)?

CARDIOVERSION. ***CARDIOVERSION*** - In a **hemodynamically unstable** patient with **supraventricular tachycardia (SVT)**, immediate **synchronized electrical cardioversion** is the treatment of choice to restore sinus rhythm rapidly and stabilize the patient. - Instability is defined by symptoms such as **hypotension**, **altered mental status**, signs of **shock**, **ischemic chest discomfort**, or **acute heart failure**. *IV Amiodarone* - While amiodarone is an **antiarrhythmic drug** used for various tachyarrhythmias, it is typically reserved for **hemodynamically stable** patients or for refractory cases after other interventions, as its onset of action is not immediate. - It works by blocking potassium channels, prolonging repolarization, and has a slower effect compared to cardioversion in an unstable setting. *IV Verapamil* - Verapamil, a **calcium channel blocker**, is used to slow the ventricular rate in SVT, particularly in stable patients. - However, in **hemodynamically unstable** patients, it can worsen **hypotension** and should be avoided. *IV Metoprolol* - Metoprolol, a **beta-blocker**, is also used to slow the heart rate in stable SVT by blocking beta-adrenergic receptors [1]. - Like verapamil, it is **contraindicated** in **hemodynamically unstable** patients due to its potential to cause or worsen **hypotension** and **cardiac depression**.

Q: Identify the condition in the provided ECG image.

Atrial flutter. ***Atrial flutter*** - The ECG shows characteristic **sawtooth flutter waves**, particularly evident in inferior leads (II, III, aVF) and V1. These represent rapid, regular atrial activity. - There is a **regular ventricular response** (narrow QRS complexes), indicating a consistent conduction ratio through the AV node, which is typical for atrial flutter with a fixed block. *Atrial fibrillation* - Characterized by **irregularly irregular R-R intervals** and the **absence of distinct P waves**, replaced by fibrillatory waves. - The ECG image displays a regular ventricular rhythm and clear flutter waves, distinguishing it from atrial fibrillation. *Cardiomyopathy* - Cardiomyopathy refers to diseases of the heart muscle and is a **structural diagnosis**, not an electrical rhythm diagnosis. - While cardiomyopathy can predispose to arrhythmias, the ECG itself directly identifies an **electrical rhythm disturbance**, not the underlying heart structure. *General arrhythmia* - This option is too broad; while atrial flutter is indeed an arrhythmia, it's essential to identify the **specific type of arrhythmia** for accurate diagnosis and management. - A more precise diagnosis is necessary to guide clinical decisions, as treatments vary significantly based on the specific arrhythmia.

Q: A patient presents to you with an irregularly irregular pulse of 120/minutes and a pulse deficit of 20. Which of the following would be the jugular venous pressure (JVP) finding?

Absent a wave. ***Absent a wave*** - An **irregularly irregular pulse** with a **pulse deficit** strongly suggests **atrial fibrillation (AF)**. - In AF, the atria quiver chaotically instead of contracting effectively, leading to the **absence of a coordinated atrial contraction** and thus an **absent 'a' wave** in the JVP. *Normal JVP* - A normal JVP would show a regular **'a' wave** corresponding to normal atrial contraction. - This is inconsistent with the **irregularly irregular pulse** and **pulse deficit** seen in the patient, which points to a significant atrial arrhythmia. *Cannon a wave* - A **cannon 'a' wave** results from the right atrium contracting against a closed tricuspid valve, leading to a large, prominent wave in the JVP. - This is typically seen in conditions like **complete heart block** or **ventricular tachycardia with AV dissociation**, not atrial fibrillation. *Raised JVP with normal waveform* - A raised JVP with a normal waveform indicates increased right atrial pressure but preserves the normal sequence of atrial contraction and relaxation. - This could be due to conditions like **right heart failure** or **volume overload**, but would still show the presence of an 'a' wave, which is absent in atrial fibrillation.

Q: Osborn J waves are seen in which of the following conditions?

Hypothermia. ***Hypothermia*** - **Osborn J waves**, or **J waves**, are characteristic electrocardiogram (ECG) findings in patients with **hypothermia**. - These waves are small, positive deflections seen at the **junction of the QRS complex and the ST segment**, most prominent in the precordial leads. *Hypocalcemia* - Hypocalcemia typically manifests on an ECG as a **prolonged QT interval** due to delayed repolarization, which can increase the risk of arrhythmias. - It does not cause Osborn J waves. *Hyperkalemia* - Hyperkalemia causes distinct ECG changes including **tall, peaked T waves**, prolonged PR interval, widened QRS complex, and ultimately sine wave formation [1]. - Osborn J waves are not associated with hyperkalemia. *Hypokalemia* - Hypokalemia is associated with ECG changes such as **flattening or inversion of T waves**, prominent U waves, and ST-segment depression [1]. - It does not lead to the formation of Osborn J waves.

Q: What are the potential causes of cardiogenic shock excluding myocardial infarction?

acute mitral regurgitation. ***acute mitral regurgitation*** - Severe acute mitral regurgitation can lead to **cardiogenic shock** by causing a sudden increase in left atrial pressure and pulmonary edema, reducing effective forward flow [1]. - This condition can result from **papillary muscle rupture** or dysfunction, often due to ischemia even in the absence of a large MI, or from infective endocarditis [1]. *ventricular septal rupture* - A ventricular septal rupture (VSR) is a mechanical complication of **myocardial infarction (MI)**, which is explicitly excluded in the question. - VSR creates a **left-to-right shunt**, leading to pulmonary overload and reduced systemic cardiac output, but it's fundamentally post-MI. *right heart failure* - While right heart failure can cause circulatory collapse, it is typically a component of **biventricular failure** or isolated in cases like severe pulmonary embolism [2]. - The question asks for causes of cardiogenic shock excluding MI, and pure **right heart failure** as a sole cause of global cardiogenic shock (affecting systemic perfusion) is less common without significant left heart involvement or severe pulmonary vascular disease. *All of the options* - This option is incorrect because **ventricular septal rupture** is almost exclusively a complication of myocardial infarction, which the question explicitly excludes. - Therefore, not all listed conditions are potential causes of cardiogenic shock *excluding MI*.

Q: In a patient presenting with an ECG that shows ST-segment elevation but with a myocardial stunning pattern that does not correspond to a single coronary artery territory, what is the most likely diagnosis?

Takotsubo cardiomyopathy. **Takotsubo cardiomyopathy** - This condition is often triggered by **severe emotional or physical stress** and presents with acute chest pain, mimicking an MI, but with a distinctive pattern of **apical ballooning** or other regional wall motion abnormalities that do not correspond to a single coronary artery territory. - The ECG findings of **ST-segment elevation** associated with a myocardial stunning pattern that does not follow a specific coronary artery distribution are classic for Takotsubo cardiomyopathy, which is also known as **stress-induced cardiomyopathy**. *Restrictive cardiomyopathy* - This is characterized by **stiff, non-compliant ventricular walls** causing impaired diastolic filling, often leading to heart failure symptoms. - While it can cause abnormal ECG findings, it typically does not present with **acute ST-segment elevation** or a myocardial stunning pattern in a non-coronary distribution. *Brugada syndrome* - This is a **genetic channelopathy** associated with characteristic **ECG patterns (ST-segment elevation in V1-V3)** and an increased risk of ventricular arrhythmias and sudden cardiac death. - It is primarily an **electrical disorder** and does not involve myocardial stunning or wall motion abnormalities that mimic an acute myocardial infarction without corresponding coronary artery disease. *Pericarditis* - This condition involves **inflammation of the pericardium**, presenting with chest pain that often improves when leaning forward and widespread, **concave ST-segment elevation** on ECG. - While it causes ST-segment elevation, it does not typically show the specific **myocardial stunning pattern** or regional wall motion abnormalities that are characteristic of Takotsubo cardiomyopathy.

Q: In which of the following conditions is the implantation of an Automatic Implantable Cardioverter Defibrillator (AICD) indicated?

Ventricular tachycardia with structural heart disease. ***Ventricular tachycardia with structural heart disease*** - An **AICD** is strongly indicated for patients with **sustained ventricular tachycardia (VT)** in the presence of **structural heart disease** due to the high risk of sudden cardiac death [1]. - In these cases, the AICD can deliver **therapy (antitachycardia pacing or defibrillation)** to terminate life-threatening arrhythmias [1]. *Syncope due to arrhythmias* - While syncope due to arrhythmias can be serious, an **AICD** is not always the first or only treatment and its indication depends on the specific arrhythmia and underlying cause. - Other treatments like **ablation**, **antiarrhythmic medications**, or a **pacemaker** might be more appropriate depending on the type of arrhythmia (e.g., bradycardia). *None of the options* - This option is incorrect because **ventricular tachycardia with structural heart disease** is a clear and well-established indication for AICD implantation [1]. - AICDs are a cornerstone in the secondary prevention of sudden cardiac death in high-risk patients. *Brugada syndrome* - While **Brugada syndrome** carries a risk of sudden cardiac death, AICD implantation is typically reserved for patients who have experienced **symptomatic arrhythmias** (e.g., syncope, aborted sudden cardiac death) or have certain high-risk features, not for all asymptomatic cases. - Risk stratification in Brugada syndrome is complex, and an AICD is not universally indicated for every diagnosed individual.

Q: Roth spots are associated with which of the following conditions?

Acute leukaemia. **Acute leukaemia** - **Roth spots** are commonly observed in patients with **leukaemia**, characterized by **retinal hemorrhages** with pale centers due to leukemic cell infiltrates [1]. - The presence of these lesions is often an indicator of severe systemic disease [1]. *Bacterial endocarditis* - While **bacterial endocarditis** can cause various **ophthalmologic manifestations** like splinter hemorrhages and Janeway lesions, **Roth spots** are distinctly identified as hemorrhages with pale centers, which, though they can occur, are less characteristically associated than with leukaemia. - These hemorrhages in endocarditis are usually attributed to **immune complex deposition** or **septic emboli**. *Severe Hypertension* - **Severe hypertension** can lead to **hypertensive retinopathy**, presenting as **retinal hemorrhages**, cotton wool spots, and papilledema. - However, the classic description of **Roth spots** with their pale centers is not a direct or prominent feature of hypertensive retinopathy. *None of the options* - This option is incorrect because **Acute leukaemia** is clearly associated with **Roth spots**.

Question 1

What is the most appropriate immediate management for a hemodynamically unstable patient with supraventricular tachycardia (SVT)?

Accepted Answer

CARDIOVERSION

Answer

IV Amiodarone

Answer

IV Verapamil

Answer

IV Metoprolol

Question 2

Which of the following statements is true about the Bundle of Kent?

Accepted Answer

It is an accessory pathway connecting the atria to the ventricles in WPW syndrome.

Answer

It is an abnormal pathway connecting the atria to the ventricles in WPW syndrome.

Answer

It is slower than the AV nodal pathway.

Answer

None of the options.

Question 3

Identify the condition in the provided ECG image.

Accepted Answer

Atrial flutter

Answer

Atrial fibrillation

Answer

Cardiomyopathy

Answer

General arrhythmia

Question 4

A patient presents to you with an irregularly irregular pulse of 120/minutes and a pulse deficit    of 20. Which of the following would be the jugular venous pressure (JVP) finding?

Accepted Answer

Absent a wave

Answer

Normal JVP

Answer

Cannon a wave

Answer

Raised JVP with normal waveform

Question 5

Osborn J waves are seen in which of the following conditions?

Accepted Answer

Hypothermia

Answer

Hypocalcemia

Answer

Hyperkalemia

Answer

Hypokalemia

Question 6

A 32-year-old patient presents to the emergency department with palpitations and dizziness. He reports that the episode started abruptly. An ECG is obtained showing a regular narrow-complex tachycardia at 180 bpm with pseudo-R′ waves visible in lead V1, consistent with retrograde P-waves. When adenosine is administered, the tachycardia terminates abruptly. Identify the cardiac rhythm shown in the image.

Accepted Answer

PSVT

Answer

Atrial Tachycardia

Answer

Ventricular Fibrillation

Answer

Ventricular Tachycardia

Question 7

What are the potential causes of cardiogenic shock excluding myocardial infarction?

Accepted Answer

acute mitral regurgitation

Answer

All of the options

Answer

ventricular septal rupture

Answer

right heart failure

Question 8

In a patient presenting with an ECG that shows ST-segment elevation but with a myocardial stunning pattern that does not correspond to a single coronary artery territory, what is the most likely diagnosis?

Accepted Answer

Takotsubo cardiomyopathy

Answer

Restrictive cardiomyopathy

Answer

Brugada syndrome

Answer

Pericarditis

Question 9

In which of the following conditions is the implantation of an Automatic Implantable Cardioverter Defibrillator (AICD) indicated?

Accepted Answer

Ventricular tachycardia with structural heart disease

Answer

None of the options

Answer

Syncope due to arrhythmias

Answer

Brugada syndrome

Question 10

Roth spots are associated with which of the following conditions?

Accepted Answer

Acute leukaemia

Answer

Bacterial endocarditis

Answer

Severe Hypertension

Answer

None of the options

Cardiology — MCQs

Cardiology — MCQs

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