Cardiology Practice Questions

Q: Refer to the provided ECG image. It demonstrates which of the following?

Ventricular fibrillation (VF). ***Ventricular fibrillation (VF)*** - The ECG shows a chaotic, **irregular electrical activity** with no distinguishable P waves, QRS complexes, or T waves. - This disorganized electrical pattern is characteristic of VF, indicating a severe cardiac emergency. *Supraventricular tachycardia (SVT)* - SVT is characterized by a **rapid, regular rhythm** with narrow QRS complexes, which are absent in this chaotic tracing. - While fast, SVT typically maintains some degree of organized electrical activity, unlike the provided ECG. *Atrial fibrillation (AF)* - AF presents with irregularly irregular rhythm and **absent P waves**, but it still has identifiable **narrow QRS complexes**. - The provided ECG lacks any discernible QRS complexes, making AF an unlikely diagnosis. *Wolff-Parkinson-White (WPW) syndrome* - WPW syndrome is characterized by a **short PR interval** and a **delta wave** on the ECG due to an accessory pathway. - It involves an organized rhythm, although it can predispose to tachyarrhythmias, and doesn't present as the chaotic rhythm shown.

Q: In a patient with heart disease, which condition is most commonly associated with left atrial enlargement?

Mitral stenosis. ***Mitral stenosis*** - **Mitral stenosis** leads to an obstruction of blood flow from the **left atrium to the left ventricle**, causing pressure buildup in the left atrium [1]. - This increased pressure over time results in **left atrial enlargement** as the chamber struggles to push blood through the narrowed valve [1]. *Tricuspid regurgitation* - **Tricuspid regurgitation** involves the backflow of blood from the **right ventricle to the right atrium**. - This condition primarily affects the **right side of the heart**, leading to **right atrial enlargement**, not left. *AR* - **Aortic regurgitation (AR)** is the backflow of blood from the **aorta into the left ventricle**. - While AR can cause **left ventricular enlargement** and eventually lead to left atrial dilation, it is not the most common direct cause of *primary* left atrial enlargement compared to mitral stenosis [2]. *None of the options* - **Mitral stenosis** is a well-established cause of significant left atrial enlargement due to the direct pressure overload it imposes on the left atrium [1].

Q: A 40-year-old male patient presents to the Emergency department with central chest pain for 2 hours. The ECG shows ST segment depression and cardiac troponins are elevated. The patient has a positive history of previous PCI 3 months back. He is administered Aspirin, Clopidogrel, Nitrates, and LMWH in the Emergency Department and shifted to the coronary care unit. What is the best recommended course of further action?

Early Revascularization with PCI. ***Early Revascularization with PCI*** - The patient presents with **NSTEMI** (ST depression, elevated troponins) and is already on antiplatelet and anticoagulant therapy. **Early revascularization** (ideally within 24 hours for high-risk NSTEMI) is indicated to restore blood flow and prevent further myocardial damage [1]. - Given the patient's history of prior **PCI** and the current NSTEMI presentation, this suggests possible **in-stent restenosis** or progression of coronary artery disease, making revascularization crucial. *Continue conservative management and monitoring of cardiac enzymes and ECG* - While initial conservative management with medications is appropriate, simply continuing monitoring without definitive intervention is insufficient for a **high-risk NSTEMI** patient. - The elevated troponins and ST depression indicate ongoing myocardial injury that requires active management beyond just observation [1]. *Continue conservative management and plan for outpatient follow-up* - This approach is entirely inappropriate for a patient presenting with an **acute coronary syndrome (NSTEMI)**. - Outpatient follow-up is for stable conditions, not for an ongoing cardiac event that requires urgent hospital-based intervention. *Immediate Revascularization with Coronary Angiography* - **Immediate revascularization** (within 90 minutes) is primarily indicated for **STEMI** (ST elevation myocardial infarction). - While coronary angiography will precede PCI, the term "immediate" in this context usually refers to the urgency seen in STEMI; NSTEMI typically warrants "early" rather than "immediate" intervention (within 12-24 hours for high-risk patients like this one) [1].

Q: Under which condition are steroids administered in rheumatic fever?

Presence of carditis. **Presence of carditis** - **Carditis** is the most serious manifestation of **rheumatic fever**, as it can lead to permanent **rheumatic heart disease** [1]. - **Corticosteroids** are administered to reduce the inflammation of the heart in cases of moderate to severe carditis, preventing or minimizing long-term damage [1]. *Presence of subcutaneous nodules* - **Subcutaneous nodules** are a minor manifestation of **rheumatic fever** and do not typically require steroid administration. - They are generally **painless** and resolve spontaneously, and their presence alone does not indicate the need for such aggressive anti-inflammatory treatment. *Presence of multiple symptoms* - The presence of **multiple minor symptoms** or asymptomatic major symptoms (other than **carditis**) does not warrant steroid use. - Steroid administration is reserved for situations with high potential for **morbidity** or **mortality**, such as severe **cardiac inflammation** [1]. *Presence of chorea* - **Sydenham's chorea** is a neurological manifestation of **rheumatic fever** and is usually managed with **antidopaminergic drugs** (e.g., haloperidol) or sedatives. - While it can be distressing, **corticosteroids** are generally not indicated for chorea unless there is co-existing **carditis** [1].

Q: Diagnose the underlying medical disorder based on the ECG changes.

ECG changes due to hypocalcemia. ***ECG changes due to hypocalcemia*** - **Hypocalcemia** characteristically causes a **prolonged QT interval** on the ECG due to delayed repolarization of ventricular myocytes. - This prolongation is primarily due to the lengthening of the **ST segment**, while the T wave itself is usually unchanged. *ECG changes due to hypokalemia* - **Hypokalemia** typically presents with prominent **U waves**, T wave flattening or inversion, and sometimes ST segment depression. - While it can also prolong the QT interval, the primary distinguishing feature is the presence of U waves, which are not mentioned as the main finding. *ECG changes due to hypercalcemia* - **Hypercalcemia** is associated with a **shortened QT interval** on the ECG due to accelerated repolarization. - It can also cause a shortened ST segment and widened QRS complex in severe cases. *ECG changes due to hyperkalemia* - **Hyperkalemia** classically manifests as tall, **peaked T waves**, followed by a prolonged PR interval, widened QRS complex, and eventual sine wave pattern as it worsens. - These changes are distinctly different from the prolonged QT interval seen in hypocalcemia.

Q: This patient came to the casualty with palpitations. His ECG has been shown below. What is your diagnosis?

Supraventricular tachycardia. ***Supraventricular tachycardia*** - The ECG shows a **narrow QRS complex tachycardia** (QRS < 0.12 seconds) with a **regular rhythm** and a **rapid ventricular rate** of 150-250 bpm, which is characteristic of SVT. The P waves may be hidden within the QRS or T waves. - While specific findings for SVT types (e.g., AVNRT, AVRT) aren't detailed without more specific ECG leads or maneuvers, the overall morphology points to a supraventricular origin. *Ventricular tachycardia* - **Ventricular tachycardia** is characterized by a **wide QRS complex** (> 0.12 seconds) tachycardia, which is not seen in the provided ECG. - It often presents with **AV dissociation** (P waves dissociated from QRS complexes) and fusion beats, which are absent here. *A-V dissociation* - **AV dissociation** refers to the atria and ventricles beating independently, which can be seen in VT or complete heart block. - It is a specific ECG finding and not a primary diagnosis, especially in the context of a narrow complex tachycardia like the one shown. *Sinus tachycardia* - **Sinus tachycardia** also presents with a narrow QRS complex but is characterized by a **normal P wave morphology** preceding each QRS complex with a rate typically not exceeding 150 bpm in an adult. - The rate in the given ECG is significantly higher, and distinct P waves are likely not preceding every QRS complex, ruling out sinus tachycardia.

Q: Torsades de pointes is seen in all except

Hyponatremia. ***Hyponatremia*** - **Hyponatremia** (low sodium levels) primarily affects neuronal function and can lead to neurological symptoms like seizures and altered mental status [1]. - It does not directly cause **QT prolongation** or **Torsades de Pointes (TdP)**, which are typically associated with electrolyte imbalances affecting cardiac repolarization. *Hypocalcemia* - **Hypocalcemia** (low calcium levels) can prolong the **QT interval** on an electrocardiogram. - Prolongation of the QT interval increases the risk of developing **Torsades de Pointes**, a life-threatening polymorphic ventricular tachycardia [2]. *Hypomagnesemia* - **Hypomagnesemia** (low magnesium levels) is a common cause and aggravator of **Torsades de Pointes**. - Magnesium plays a crucial role in cardiac ion channel function, and its deficiency can lead to significant **QT prolongation** and ventricular arrhythmias. *Hypokalemia* - **Hypokalemia** (low potassium levels) can prolong the **QT interval** and increase the risk of developing ventricular arrhythmias, including **Torsades de Pointes** [1]. - Potassium channels are essential for cardiac repolarization, and their dysfunction due to low potassium can destabilize myocardial electrical activity [1].

Q: Which of the following is associated with WPW syndrome?

Ebstein anomaly. ***Ebstein anomaly*** - **Ebstein anomaly** is a congenital heart defect characterized by apical displacement of the septal and posterior leaflets of the tricuspid valve, which is strongly associated with **Wolff-Parkinson-White (WPW) syndrome.** - WPW syndrome, involving an **accessory pathway** that bypasses the AV node [1], is found in 5-25% of patients with Ebstein anomaly, predisposing them to re-entrant tachycardias [3]. *TOF* - **Tetralogy of Fallot (TOF)** is a complex cyanotic congenital heart defect that includes four main features: VSD, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy [2]. - There is no direct or strong association between TOF and WPW syndrome. *VSD* - A **Ventricular Septal Defect (VSD)** is a common congenital heart defect where there is an opening in the interventricular septum, allowing blood to flow between the ventricles [4]. - While VSDs can occur with other cardiac anomalies, there is no specific or frequent association with WPW syndrome. *TAPVC* - **Total Anomalous Pulmonary Venous Connection (TAPVC)** is a rare congenital heart defect where all four pulmonary veins connect to the systemic venous circulation instead of the left atrium. - This condition does not have a recognized association with WPW syndrome.

Q: Graham Steell murmur is associated with which of the following conditions?

Pulmonary Regurgitation (PR). ***Pulmonary Regurgitation (PR)*** - The **Graham Steell murmur** is a high-pitched, decrescendo early diastolic murmur heard best at the left sternal border associated with **pulmonary hypertension**. [1] - It results from dilation of the pulmonary artery due to **elevated pulmonary pressures**, leading to functional pulmonary valve regurgitation. [1] *Tricuspid Regurgitation (TR)* - TR typically presents as a **holosystolic murmur** best heard at the left lower sternal border, often increasing with inspiration (Carvallo's sign). - It is caused by improper coaptation of the tricuspid valve leaflets, often due to **right ventricular dilation**. *Tricuspid Stenosis (TS)* - TS is characterized by a **diastolic rumble** heard best at the lower left sternal border, often with an opening snap. [2] - It is relatively rare and often associated with **rheumatic heart disease**. *Pulmonary Stenosis (PS)* - PS typically produces a **systolic ejection murmur** heard at the upper left sternal border, often radiating to the back. - It is caused by **obstruction to blood flow** from the right ventricle to the pulmonary artery.

Question 1

Refer to the provided ECG image. It demonstrates which of the following?

Accepted Answer

Ventricular fibrillation (VF)

Answer

Supraventricular tachycardia (SVT)

Answer

Atrial fibrillation (AF)

Answer

Wolff-Parkinson-White (WPW) syndrome

Question 2

In a patient with heart disease, which condition is most commonly associated with left atrial enlargement?

Accepted Answer

Mitral stenosis

Answer

Tricuspid regurgitation

Answer

AR

Answer

None of the options

Question 3

A 40-year-old male patient presents to the Emergency department with central chest pain for 2 hours. The ECG shows ST segment depression and cardiac troponins are elevated. The patient has a positive history of previous PCI 3 months back. He is administered Aspirin, Clopidogrel, Nitrates, and LMWH in the Emergency Department and shifted to the coronary care unit. What is the best recommended course of further action?

Accepted Answer

Early Revascularization with PCI

Answer

Continue conservative management and monitoring of cardiac enzymes and ECG

Answer

Continue conservative management and plan for outpatient follow-up

Answer

Immediate Revascularization with Coronary Angiography

Question 4

Under which condition are steroids administered in rheumatic fever?

Accepted Answer

Presence of carditis

Answer

Presence of subcutaneous nodules

Answer

Presence of multiple symptoms

Answer

Presence of chorea

Question 5

Diagnose the underlying medical disorder based on the ECG changes.

Accepted Answer

ECG changes due to hypocalcemia

Answer

ECG changes due to hypokalemia

Answer

ECG changes due to hypercalcemia

Answer

ECG changes due to hyperkalemia

Question 6

What is the most likely cause of fluid overload in a patient presenting with shortness of breath?

Accepted Answer

Cardiac failure

Answer

Nephritic syndrome

Answer

TB

Answer

Portal hypertension

Question 7

This patient came to the casualty with palpitations. His ECG has been shown below. What is your diagnosis?

Accepted Answer

Supraventricular tachycardia

Answer

Ventricular tachycardia

Answer

A-V dissociation

Answer

Sinus tachycardia

Question 8

Torsades de pointes is seen in all except

Accepted Answer

Hyponatremia

Answer

Hypomagnesemia

Answer

Hypokalemia

Answer

Hypocalcemia

Question 9

Which of the following is associated with WPW syndrome?

Accepted Answer

Ebstein anomaly

Answer

TOF

Answer

VSD

Answer

TAPVC

Question 10

Graham Steell murmur is associated with which of the following conditions?

Accepted Answer

Pulmonary Regurgitation (PR)

Answer

Tricuspid Regurgitation (TR)

Answer

Tricuspid Stenosis (TS)

Answer

Pulmonary Stenosis (PS)

Cardiology — MCQs

Cardiology — MCQs

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