Cardiology Practice Questions

Q: Hockey stick appearance on echo is a feature of.

Mitral stenosis. ***Mitral stenosis*** - The **"hockey stick" appearance** on echocardiography refers to the characteristic **doming of the anterior mitral leaflet** during diastole, which is a hallmark of mitral stenosis. - This doming is due to the stenotic mitral valve opening incompletely, with the tip of the leaflet bending forward while its base remains tethered [1]. *Mitral incompetence* - **Mitral incompetence (regurgitation)** is characterized by **incomplete closure** of the mitral valve leaflets, leading to backward blood flow into the left atrium during systole. - This condition does not typically present with a "hockey stick" appearance; instead, it is often seen with **leaflet prolapse** or inadequate coaptation [1]. *Aortic stenosis* - **Aortic stenosis** involves the **narrowing of the aortic valve**, impeding blood flow from the left ventricle to the aorta. - Its echocardiographic features include **thickened, calcified aortic valve leaflets** with reduced excursion, not a "hockey stick" appearance. *Aortic regurgitation* - **Aortic regurgitation** is the backward flow of blood from the aorta into the left ventricle during diastole due to **incomplete closure of the aortic valve** [2]. - While it can manifest with various echocardiographic signs like **diastolic flow reversal** in the aorta, the "hockey stick" sign is not associated with this condition [2].

Q: Positive hepatojugular reflux is found in all of the following conditions except -

Decreased afterload. ***Decreased afterload*** - **Hepatojugular reflux** is a sign of **right-sided heart dysfunction** [1] where compressing the liver increases jugular venous pressure due to impaired right ventricular filling [2]. - **Decreased afterload** would typically improve cardiac output and reduce intracardiac pressures, making hepatojugular reflux less likely. *Tricuspid regurgitation* - **Tricuspid regurgitation** leads to increased right atrial pressure [2], which can cause engorgement of the liver and an exaggerated hepatojugular reflux. - This condition directly impacts the ability of the right ventricle to empty effectively, contributing to systemic venous congestion. *Right heart failure* - **Right heart failure** is a common cause of hepatojugular reflux due to elevated right atrial and central venous pressures [1]. - The failing right ventricle is unable to handle increased venous return, leading to reflux. *Increased capillary bed pressure* - **Increased capillary bed pressure** in the systemic circulation, often secondary to **right heart failure** [2] or **volume overload**, contributes to elevated venous pressures. - This increased pressure can be transmitted back to the right atrium, leading to a positive hepatojugular reflux.

Q: What is an electrical storm?

3 episodes of ventricular tachycardia within 24 hours. ***3 episodes of ventricular tachycardia within 24 hours*** - An **electrical storm**, also known as **arrhythmia storm**, is defined by the occurrence of **three or more distinct episodes of ventricular tachycardia (VT)**, ventricular fibrillation (VF), or appropriate implantable cardioverter-defibrillator (ICD) shocks within a 24-hour period [1]. - This condition signifies **severe myocardial electrical instability** and is associated with increased morbidity and mortality [1]. *Electromechanical dissociation* - **Electromechanical dissociation (EMD)**, or pulseless electrical activity (PEA), describes a situation where there is organized electrical activity on an electrocardiogram but **no palpable pulse**. - It is a form of cardiac arrest and is distinct from an arrhythmia storm, which specifically refers to recurrent ventricular arrhythmias. *Electrical alternans* - **Electrical alternans** is an electrocardiographic phenomenon characterized by **beat-to-beat alterations in the QRS complex amplitude or axis**. - It is often associated with **pericardial effusion with cardiac tamponade** and is not indicative of recurrent ventricular tachyarrhythmias. *3 episodes of atrial tachycardia within 24 hours* - While recurrent **atrial tachycardia** indicates electrical instability in the atria, an "electrical storm" specifically refers to **ventricular arrhythmias** [1]. - Atrial arrhythmias, though potentially serious, do not meet the diagnostic criteria for an electrical storm.

Q: A 45-year-old man presents to the emergency department with sudden onset shortness of breath and pleuritic chest pain. He recently returned from a long-haul flight. His heart rate is 112 bpm and oxygen saturation is 91% on room air. The given ECG shows the following findings:

Acute pulmonary embolism. ***Acute pulmonary embolism*** - This ECG shows the classic **S1Q3T3 pattern**, characterized by a **prominent S wave in lead I**, a **Q wave in lead III**, and an **inverted T wave in lead III**, which is suggestive of acute pulmonary embolism in the appropriate clinical context. - Other common ECG findings in pulmonary embolism include **sinus tachycardia**, all pointing to acute right heart strain. - Note: The S1Q3T3 pattern is neither sensitive nor specific enough to diagnose pulmonary embolism in isolation; clinical correlation and further imaging (e.g., CT pulmonary angiography) are required for definitive diagnosis. *Hypertrophic cardiomyopathy (HCM)* - HCM typically presents with **deep, narrow Q waves** in the inferolateral leads (II, III, aVF, V5, V6) due to septal hypertrophy. - It usually does not exhibit the S1Q3T3 pattern. *Pericardial effusion (PE)* - Pericardial effusion usually causes **low voltage QRS complexes** and **electrical alternans** due to the fluid surrounding the heart. - It does not present with the specific S1Q3T3 pattern seen here. *Anterior wall myocardial infarction (MI)* - Anterior MI is characterized by **ST-segment elevation** (or Q waves in later stages) in the anterior leads (V1-V4). - While it can cause T wave inversions, it would not typically show the S1Q3T3 pattern.

Q: What is the immediate treatment modality for a patient presenting with acute anterior wall myocardial infarction and hypotension?

Primary Percutaneous Coronary Intervention (Primary PCI). ***Primary Percutaneous Coronary Intervention (Primary PCI)*** - **Primary PCI**, guided by coronary angiography, is the **gold standard** for treating ST-elevation myocardial infarction (STEMI) because it directly restores blood flow to the *ischemic* myocardium. - In a patient with **acute anterior wall MI and hypotension**, immediate revascularization via Primary PCI is crucial to improve cardiac output and stabilize hemodynamics, as hypotension often implies significant myocardial damage and *cardiogenic shock*. - Guidelines recommend Primary PCI within **90 minutes** of first medical contact (door-to-balloon time) when available. *Thrombolytic therapy* - While thrombolysis can restore blood flow, it is considered a **second-line treatment** if PCI is unavailable or significantly delayed (>120 minutes from first medical contact). - It carries a higher risk of bleeding complications and may not achieve complete reperfusion, especially in patients with **hypotension** or *cardiogenic shock*. *Anticoagulation* - Anticoagulation is an **adjunctive therapy** used to prevent further clot formation and maintain coronary artery patency after reperfusion. - It is **not a definitive revascularization strategy** on its own and does not immediately address the acute coronary occlusion causing the MI and hypotension. *Intra-aortic balloon counterpulsation (IABP)* - **IABP** is a mechanical circulatory support device used to reduce *afterload* and increase *coronary perfusion*, primarily in patients with **cardiogenic shock** awaiting or recovering from revascularization. - While beneficial for hemodynamic support, it is **not the primary reperfusion treatment** and should be used in conjunction with immediate PCI, not as a substitute.

Q: Accelerated idioventricular rhythm (AIVR) is most characteristically seen in?

Myocardial reperfusion. ***Myocardial reperfusion*** - **Accelerated idioventricular rhythm (AIVR)** is a common reperfusion arrhythmia, often seen after successful restoration of blood flow to the ischemic myocardium following a myocardial infarction. - The sudden influx of oxygen and nutrients can trigger **automaticity** in the ventricular myocardium, leading to this rhythm. *Atrioventricular nodal block* - While AV nodal block can lead to escape rhythms from lower pacemakers, **AIVR** is a specific ventricular rhythm typically associated with **reperfusion injury**, not primarily with AV block itself. - AV nodal block often results in a slower **junctional or ventricular escape rhythm**, rather than an *accelerated* ventricular rhythm. *Electrolyte imbalance* - Severe electrolyte imbalances, such as **hyperkalemia** or **hypokalemia**, can cause various arrhythmias, including ventricular tachycardias or bradycardias. - However, **AIVR** has a much stronger and more characteristic association with **myocardial reperfusion** than with general electrolyte derangements. *Digitalis therapy* - **Digitalis toxicity** can cause a wide range of arrhythmias, including ventricular ectopy, bigeminy, and even ventricular tachycardia. - While it can increase ventricular automaticity, **AIVR** is not the *most characteristic* arrhythmia specifically linked to digitalis toxicity; other arrhythmias like **bidirectional ventricular tachycardia** are more classic.

Q: What is the most common site of acute aortic dissection?

Ascending aorta. ***Ascending aorta*** - The **ascending aorta** is the most common site for **acute aortic dissection**, particularly within a few centimeters of the **aortic valve** [1]. - This region is under the highest **hemodynamic stress**, making it more susceptible to intimal tear and dissection. *Arch of aorta* - While dissections can propagate into or originate in the **arch of the aorta**, it is a less common primary site compared to the ascending aorta [1]. - Involvement of the arch often occurs as an extension of a more proximal dissection. *Suprarenal abdominal aorta* - The **abdominal aorta** is less commonly affected by acute dissection compared to the thoracic aorta [1]. - When dissection does occur in the abdominal aorta, it is generally an extension from a thoracic dissection and rarely originates primarily here. *Infrarenal abdominal aorta* - The **infrarenal abdominal aorta** is the most common site for **abdominal aortic aneurysms**, but it is an infrequent primary site for acute aortic dissection [2]. - Dissections originating here are rare, though dissections can extend to this segment.

Q: Duration of pain in angina is:

2-5 mins. **2-5 mins** - **Stable angina** chest pain typically lasts for a few minutes, usually 2 to 5 minutes, and is precipitated by exertion or stress [1]. - Pain is **relieved by rest** or nitroglycerin within minutes [1]. *5-30 mins* - This duration is longer than typical stable angina and could indicate **unstable angina** or another cardiac event, requiring immediate medical evaluation [1]. - While an myocardial infarction (MI) is a possibility, pain lasting this specific duration is not the hallmark of stable angina [1]. *30-60 mins* - This duration is characteristic of prolonged cardiac ischemia, such as an **acute myocardial infarction (heart attack)**, rather than stable angina [1]. - Such prolonged pain signals serious heart damage and requires urgent medical intervention [2]. *> 1 hour* - Pain lasting over an hour is atypical for angina and strongly suggests an **acute myocardial infarction (MI)** or other non-cardiac causes like pericarditis or aortic dissection. - **Angina pain is generally brief** and resolves quickly [1].

Q: In acute left ventricular failure with pulmonary edema, which drug can be administered for immediate management?

Morphine. ***Morphine*** - **Morphine** is a key drug in the **acute management of left ventricular failure with pulmonary edema** - It provides **anxiolysis**, reduces **sympathetic drive**, and decreases **preload** through venodilation - Reduces **oxygen demand** and **work of breathing** in acute decompensation - Standard dose: **2-5 mg IV**, can be repeated as needed - Caution needed for **respiratory depression** and **hypotension**, but benefits outweigh risks in severe pulmonary edema *Propranolol* - **Propranolol** is a **non-selective beta-blocker** that is **contraindicated in acute/decompensated heart failure** - Beta-blockers **reduce contractility** and can worsen acute cardiac output - While certain beta-blockers (carvedilol, metoprolol, bisoprolol) are used in **chronic stable heart failure**, propranolol is NOT a guideline-recommended agent for heart failure management - In acute settings, beta-blockers would precipitate or worsen decompensation *Amlodipine* - **Amlodipine** is a **dihydropyridine calcium channel blocker** used for hypertension and angina - **Not recommended in heart failure** as it can cause **negative inotropic effects** and peripheral edema - Does not provide mortality benefit and may worsen outcomes in LV dysfunction - Other vasodilators (nitrates, ACE inhibitors) are preferred *Epinephrine* - **Epinephrine** is a potent **catecholamine** with alpha and beta effects - Increases **heart rate**, **contractility**, and **systemic vascular resistance** - Would dramatically increase **myocardial oxygen demand** and **afterload** in LV failure - Reserved for **cardiac arrest** or **cardiogenic shock requiring inotropic support**, not routine LV failure management - Risk of **arrhythmias** and **ischemia**

Question 1

Hockey stick appearance on echo is a feature of.

Accepted Answer

Mitral stenosis

Answer

Mitral incompetence

Answer

Aortic stenosis

Answer

Aortic regurgitation

Question 2

Positive hepatojugular reflux is found in all of the following conditions except -

Accepted Answer

Decreased afterload

Answer

Tricuspid regurgitation

Answer

Increased capillary bed pressure

Answer

Right heart failure

Question 3

Which of the following statements regarding hypertensive crisis is false?

Accepted Answer

Hypertensive emergencies require immediate reduction of blood pressure over hours to prevent end-organ damage.

Answer

Hypertensive urgencies may be managed without extensive monitoring on an outpatient basis.

Answer

Hypertensive urgency is characterized by marked elevation of blood pressure without rapidly evolving end organ damage.

Answer

None of the options.

Question 4

What is an electrical storm?

Accepted Answer

3 episodes of ventricular tachycardia within 24 hours

Answer

Electromechanical dissociation

Answer

Electrical alternans

Answer

3 episodes of atrial tachycardia within 24 hours

Question 5

A 45-year-old man presents to the emergency department with sudden onset shortness of breath and pleuritic chest pain. He recently returned from a long-haul flight. His heart rate is 112 bpm and oxygen saturation is 91% on room air. The given ECG shows the following findings:

Accepted Answer

Acute pulmonary embolism

Answer

Hypertrophic cardiomyopathy (HCM)

Answer

Anterior wall myocardial infarction (MI)

Answer

Pericardial effusion (PE)

Question 6

What is the immediate treatment modality for a patient presenting with acute anterior wall myocardial infarction and hypotension?

Accepted Answer

Primary Percutaneous Coronary Intervention (Primary PCI)

Answer

Anticoagulation

Answer

Thrombolytic therapy

Answer

Intra-aortic balloon counterpulsation

Question 7

Accelerated idioventricular rhythm (AIVR) is most characteristically seen in?

Accepted Answer

Myocardial reperfusion

Answer

Digitalis therapy

Answer

Atrioventricular nodal block

Answer

Electrolyte imbalance

Question 8

What is the most common site of acute aortic dissection?

Accepted Answer

Ascending aorta

Answer

Arch of aorta

Answer

Suprarenal abdominal aorta

Answer

Infrarenal abdominal aorta

Question 9

Duration of pain in angina is:

Accepted Answer

2-5 mins

Answer

5-30 mins

Answer

30-60 mins

Answer

> 1 hour

Question 10

In acute left ventricular failure with pulmonary edema, which drug can be administered for immediate management?

Accepted Answer

Morphine

Answer

Amlodipine

Answer

Epinephrine

Answer

Propranolol

Cardiology — MCQs

Cardiology — MCQs

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