Cardiology Practice Questions

Q: Which of the following is not a component of Jones criteria for diagnosing acute rheumatic fever?

Erythema nodosum. ***Erythema nodosum*** - **Erythema nodosum** is a delayed hypersensitivity reaction characterized by tender, red nodules, typically on the shins, but it is **not a major or minor criterion** in the Jones criteria for acute rheumatic fever. - While it can be associated with various inflammatory conditions, including streptococcal infections, its presence alone does not establish a diagnosis of **acute rheumatic fever (ARF)**. *Sydenham chorea* - **Sydenham chorea** is a major manifestation of ARF, characterized by involuntary, purposeless movements, and it is a key diagnostic criterion [1]. - It results from central nervous system involvement due to **autoimmune reaction** against basal ganglia. *Pancarditis* - **Pancarditis** (inflammation of all layers of the heart) is a major criterion for ARF, often leading to valvular damage, especially mitral stenosis [1]. - It can manifest as **pericarditis**, **myocarditis**, or **endocarditis** [1]. *Migratory polyarthritis* - **Migratory polyarthritis** is a major criterion for ARF, involving painful inflammation that moves from one joint to another. - It typically affects large joints such as the **knees, ankles, elbows, and wrists**.

Q: Continuous murmur is heard in?

Patent ductus arteriosus. ***Patent ductus arteriosus*** - A **continuous murmur** in PDA is often described as a **"machinery-like" murmur**, audible throughout systole and diastole [1]. - This murmur is caused by the continuous flow of blood from the higher-pressure aorta into the lower-pressure pulmonary artery [1]. *Tetralogy of Fallot* - The murmur associated with Tetralogy of Fallot is typically a **systolic ejection murmur** heard at the upper left sternal border [1]. - This murmur is due to pulmonary stenosis and is not continuous, as it is related to ventricular ejection [1]. *Ventricular septal defect* - A VSD typically presents with a **holosystolic murmur**, meaning it is heard throughout systole [1]. - The murmur in VSD is confined to systole and does not extend into diastole, distinguishing it from a continuous murmur [1]. *Atrial septal defect* - An ASD is typically associated with a **systolic ejection murmur** over the pulmonic area due to increased flow across the pulmonary valve [1]. - There may also be a **diastolic rumble** across the tricuspid valve, but neither of these is a continuous murmur [1].

Q: Which of the following is seen in mitral stenosis?

Diastolic murmur. ***Diastolic murmur*** - **Mitral stenosis** is characterized by a narrowing of the mitral valve, impeding blood flow from the left atrium to the left ventricle during **diastole**. - This turbulent flow during ventricular filling produces a characteristic **diastolic murmur**, often described as a low-pitched, rumbling sound [1], [3]. *None of the options* - This option is incorrect because **mitral stenosis** is indeed associated with a specific heart sound abnormality [1]. - The presence of a **diastolic murmur** is a hallmark physical finding in patients with mitral stenosis [1]. *Systolic murmur* - A **systolic murmur** is produced during ventricular contraction (systole), typically associated with **mitral regurgitation** or **aortic stenosis** [2]. - In **mitral stenosis**, the primary pathology is during diastole, making a systolic murmur less characteristic unless there's concomitant mitral regurgitation. *Loud S2* - A **loud S2** (second heart sound) can be heard in conditions like **pulmonary hypertension** or **systemic hypertension**. - While pulmonary hypertension can be a complication of severe **mitral stenosis** due to elevated left atrial pressure, a loud S2 is not the most direct or specific auscultatory finding for mitral stenosis itself; the distinct diastolic murmur is more characteristic [1].

Q: A patient after valve replacement will require follow up treatment with

Warfarin. ***Warfarin*** - Patients with **mechanical prosthetic heart valves** require lifelong anticoagulation with **warfarin** to prevent life-threatening thromboembolic complications [1]. - The target **international normalized ratio (INR)** typically ranges from 2.5 to 3.5, depending on the valve type and position. *ACE inhibitors* - **ACE inhibitors** are primarily used for managing **hypertension**, **heart failure**, and **renal protection**, not as routine post-valve replacement prophylaxis [2]. - While they may be used if these co-morbidities exist, they are not a universal requirement after valve surgery. *Beta blockers* - **Beta blockers** are often prescribed to control heart rate, manage **hypertension**, or reduce myocardial oxygen demand, but they are not the primary follow-up treatment for all valve replacement patients. - They do not address the critical need for **anticoagulation** in mechanical valve recipients. *Thiazide* - **Thiazide diuretics** are used to treat **hypertension** and **edema** by increasing salt and water excretion. - They do not play a direct role in preventing **thromboembolism** post-valve replacement and are not generally indicated unless chronic heart failure or hypertension is present.

Q: Which heart sound is almost always considered pathological?

S4. ***S4*** - An **S4 heart sound**, or **atrial gallop**, is almost always indicative of **pathology**, specifically a **stiff or non-compliant ventricle**. - It occurs due to vigorous atrial contraction forcing blood into a **non-compliant ventricle**, commonly seen in conditions like **hypertensive heart disease**, **aortic stenosis**, and **hypertrophic cardiomyopathy**. *S2* - **S2** represents the **closure of the aortic and pulmonic valves** and is a normal physiological heart sound [2]. - While it can be altered in pathology (e.g., fixed splitting, paradoxical splitting), the sound itself is a normal component of the cardiac cycle [1]. *S1* - **S1** represents the **closure of the mitral and tricuspid valves** and is a normal physiological heart sound [1]. - Variations in its intensity or splitting can occur in disease states, but the presence of S1 itself is normal. *S3* - An **S3 heart sound**, or **ventricular gallop**, can be a normal finding in **children**, **young adults**, and **pregnant individuals**, often referred to as a **physiological S3**. - However, in adults over 40, an S3 often indicates **ventricular dysfunction** due to rapid filling into a dilated ventricle [3], as seen in **heart failure** [1].

Q: Single heart sound (S2) is heard in:

Tetralogy of Fallot. ***Tetralogy of Fallot*** - A **single S2 heart sound** is characteristic of Tetralogy of Fallot due to the **pulmonary stenosis** (or atresia) which prevents the closure sound of the pulmonary valve from being heard [1]. - The single S2 heard is typically the **aortic component** (A2), as the pulmonary component (P2) is diminished or absent [1]. *Transposition of great vessels* - This condition is often associated with a **loud, single S2** because the aorta arises from the right ventricle, but a split S2 can occur if there is a large patent ductus arteriosus or ventricular septal defect. - The S2 is usually composed mainly of the **aortic component**, which is anteriorly placed. *Ebstein's anomaly* - Characterized by the downward displacement of the **tricuspid valve leaflets** into the right ventricle. - This typically results in a **wide, fixed splitting of S2** and can be associated with a gallop rhythm due to S3 and S4 sounds [2]. *TAPVC (Total Anomalous Pulmonary Venous Connection)* - TAPVC typically presents with a **widely split and fixed S2** due to increased blood flow through the pulmonary circulation. - When there is an obstruction, the P2 component can be louder, and a **gallop rhythm** might be present, but a single S2 is not a primary feature.

Q: Which of the following is not associated with pulmonary arterial hypertension?

Left ventricular hypertrophy. ***Left ventricular hypertrophy*** - **Left ventricular hypertrophy** is typically caused by conditions that increase the workload on the left ventricle, such as **systemic hypertension** or **aortic stenosis** [1]. - Pulmonary arterial hypertension directly affects the **pulmonary vasculature**, leading to increased pressure in the pulmonary circuit and ultimately right heart strain, not left ventricular hypertrophy. *Cor pulmonale* - **Cor pulmonale** is defined as **right ventricular enlargement** secondary to lung disease or pulmonary vascular disease. - Pulmonary arterial hypertension increases the afterload on the right ventricle, causing it to dilate and hypertrophy, eventually leading to **right heart failure** (cor pulmonale) [2]. *Mitral Stenosis* - **Mitral stenosis** causes an obstruction to blood flow from the left atrium to the left ventricle, leading to increased pressure in the left atrium and pulmonary veins. - This elevated pressure can be transmitted backward into the pulmonary arteries, leading to **pulmonary arterial hypertension** [3]. *Interstitial lung disease* - **Interstitial lung disease** (ILD) can lead to destruction and remodeling of the pulmonary capillaries, increasing pulmonary vascular resistance [2]. - This increased resistance causes the pulmonary arterial pressure to rise, resulting in **pulmonary arterial hypertension**.

Q: On ECG, ST segment elevation is seen in all of the following conditions EXCEPT:

Hypocalcemia. ***Hypocalcemia*** - While hypocalcemia affects cardiac electrical activity by prolonging the **QT interval**, it is not typically associated with **ST segment elevation**. [3] - The primary ECG finding in hypocalcemia is a **prolonged ST segment**, which then leads to a prolonged QT interval, not an elevated ST segment. *Acute pericarditis* - Characteristically presents with **diffuse concave ST segment elevation** in many leads, often accompanied by **PR segment depression**. - This is due to inflammation of the pericardium affecting the epicardial layer of the myocardium. *Myocardial infarction* - **ST segment elevation** is a hallmark of an acute **ST-segment elevation myocardial infarction (STEMI)**, indicating transmural ischemia. [1], [2] - The location of ST elevation corresponds to the affected coronary artery and myocardial territory. [4] *Left ventricular aneurysm* - Can cause **persistent ST segment elevation** in the leads corresponding to the aneurysm, even after the acute phase of a myocardial infarction. - This persistent elevation is thought to be due to **dyskinetic or akinetic wall motion** and altered repolarization in the scarred tissue.

Q: Which of the following is not true regarding Wolff-Parkinson-White (WPW) syndrome?

Prolonged PR interval. ***Prolonged PR interval*** - In WPW syndrome, the presence of an **accessory pathway (Bundle of Kent)** allows for **pre-excitation** of the ventricles, bypassing the AV node's normal delay [1]. - This results in a **shortened PR interval** (typically < 0.12 seconds), not a prolonged one [1]. *Delta wave is seen on ECG* - The **delta wave** is a characteristic finding in WPW, representing the slurred upstroke of the QRS complex due to early ventricular activation via the accessory pathway [1]. - It indicates **ventricular pre-excitation** and is a key diagnostic feature [1], [2]. *Bundle of Kent connects atria to ventricles* - The **Bundle of Kent** is an anomalous muscle fiber bundle that forms an **accessory pathway** directly connecting the atria to the ventricles [1]. - This pathway bypasses the AV node, leading to the characteristic ECG findings and potential re-entrant arrhythmias. *Pre-excitation occurs via accessory pathway* - **Pre-excitation** is the hallmark of WPW syndrome, where electrical impulses bypass the normal conduction system (AV node) and activate ventricular tissue prematurely via an **accessory pathway** [1]. - This leads to the characteristic short PR interval and delta wave on the ECG [2].

Q: A 52-year-old woman has long-standing rheumatoid arthritis (RA) and is being treated with corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs). Which of the following cardiac complications may arise in this clinical setting?

Constrictive pericarditis. ***Constrictive pericarditis*** - Chronic **inflammation** associated with rheumatoid arthritis can lead to pericardial involvement, often manifesting as **pericardial effusion** or **fibrosis**. [1] - Over time, this fibrosis can progress to **pericardial thickening** and calcification, impairing diastolic filling and causing symptoms of constrictive pericarditis. [1] *Hypertrophic cardiomyopathy* - This condition is characterized by **left ventricular hypertrophy** without an identifiable cause like hypertension or aortic stenosis. - It is primarily a **genetic disorder** of the sarcomere and is not typically associated with rheumatoid arthritis or its treatments. [2] *Restrictive cardiomyopathy* - Characterized by stiff, non-compliant ventricular walls that restrict diastolic filling, often due to **infiltrative diseases** like amyloidosis or sarcoidosis. [2] - While RA can cause amyloidosis, it is not the most direct or common cardiac complication, and this diagnosis focuses on myocardial stiffness rather than pericardial disease. [3, 4] *Dilated cardiomyopathy* - Involves **enlargement and weakening** of the heart ventricles, leading to impaired systolic function. - It can be caused by various factors including viral infections, alcohol, or genetic predisposition, but is not a typical direct cardiac complication of rheumatoid arthritis. [2]

Question 1

Which of the following is not a component of Jones criteria for diagnosing acute rheumatic fever?

Accepted Answer

Erythema nodosum

Answer

Sydenham chorea

Answer

Pancarditis

Answer

Migratory polyarthritis

Question 2

Continuous murmur is heard in?

Accepted Answer

Patent ductus arteriosus

Answer

Tetralogy of fallot

Answer

Ventricular septal defect

Answer

Atrial septal defect

Question 3

Which of the following is seen in mitral stenosis?

Accepted Answer

Diastolic murmur

Answer

None of the options

Answer

Systolic murmur

Answer

Loud S2

Question 4

A patient after valve replacement will require follow up treatment with

Accepted Answer

Warfarin

Answer

ACE inhibitors

Answer

Beta blockers

Answer

Thiazide

Question 5

Which heart sound is almost always considered pathological?

Accepted Answer

S4

Answer

S2

Answer

S1

Answer

S3

Question 6

Single heart sound (S2) is heard in:

Accepted Answer

Tetralogy of Fallot

Answer

Transposition of great vessels

Answer

Ebstein's anomaly

Answer

TAPVC

Question 7

Which of the following is not associated with pulmonary arterial hypertension?

Accepted Answer

Left ventricular hypertrophy

Answer

Cor - pulmonale

Answer

Mitral Stenosis

Answer

Interstitial lung disease

Question 8

On ECG, ST segment elevation is seen in all of the following conditions EXCEPT:

Accepted Answer

Hypocalcemia

Answer

Acute pericarditis

Answer

Myocardial infarction

Answer

Left ventricular aneurysm

Question 9

Which of the following is not true regarding Wolff-Parkinson-White (WPW) syndrome?

Accepted Answer

Prolonged PR interval

Answer

Delta wave is seen on ECG

Answer

Bundle of Kent connects atria to ventricles

Answer

Pre-excitation occurs via accessory pathway

Question 10

A 52-year-old woman has long-standing rheumatoid arthritis (RA) and is being treated with corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs). Which of the following cardiac complications may arise in this clinical setting?

Accepted Answer

Constrictive pericarditis

Answer

Hypertrophic cardiomyopathy

Answer

Restrictive cardiomyopathy

Answer

Dilated cardiomyopathy

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