Cardiology Practice Questions

Q: A healthy middle-aged man who became emotionally upset during an argument with his brother suddenly developed chest pain and collapsed. He was declared dead upon arrival at the hospital. What is the most likely diagnosis?

Takotsubo cardiomyopathy. ***Takotsubo cardiomyopathy*** - Presents with sudden **chest pain** and collapse following **severe emotional stress**, mimicking a myocardial infarction but often without significant coronary artery disease. - It involves dramatic and transient left ventricular systolic dysfunction, often described as **apical ballooning**, that can lead to acute heart failure and sudden death. *Dilated cardiomyopathy* - Typically presents with **progressive heart failure symptoms** such as dyspnea and fatigue, not sudden collapse after acute emotional stress. - It is characterized by **ventricular dilation** and impaired systolic function, developing over time from various causes. *Arrhythmogenic right ventricle dysplasia* - This condition primarily affects the **right ventricle**, leading to fibrofatty replacement of myocardial tissue and increasing the risk of **ventricular arrhythmias** and sudden cardiac death, especially during exertion. - The presentation of sudden collapse after emotional stress, without prior athletic activity, makes it less likely than Takotsubo cardiomyopathy. *Chronic ischemic cardiomyopathy* - This condition results from **long-standing coronary artery disease**, leading to **myocardial remodeling**, reduced systolic function, and chronic heart failure. - While it can cause sudden cardiac death due to arrhythmias, the acute onset after emotional upset in an otherwise healthy individual is less typical for a chronic process [1].

Q: In which condition are epsilon waves observed on an ECG?

RV dysplasia. RV dysplasia - **Epsilon waves** are small, positive deflections (after the QRS complex) seen on an ECG, pathognomonic for **Arrhythmogenic Right Ventricular Dysplasia (ARVD)**. - ARVD is a genetic disorder where the muscle tissue of the right ventricle is replaced by **fibrofatty tissue**, leading to arrhythmias. *Hypothermia* - Hypothermia is associated with **Osborn waves** (J waves), which are positive deflections at the QRS-ST junction, not epsilon waves. - Other ECG changes in hypothermia include **bradycardia**, prolongation of PR, QRS, and QT intervals. *Takotsubo cardiomyopathy* - This condition typically presents with **ST-segment elevation** and T-wave inversions, mimicking an acute myocardial infarction, but lacks coronary artery disease. - It is characterized by **transient apical ballooning** of the left ventricle, usually triggered by severe emotional or physical stress. *None of the options* - This option is incorrect because **RV dysplasia** specifically features epsilon waves, making it a correct choice. - Epsilon waves are a distinct and recognizable ECG finding associated with this particular cardiac condition.

Q: Which of the following is the most appropriate true statement regarding ostium primum atrial septal defect (ASD)?

Is unlikely to close spontaneously. Current guidelines indicate that **ostium primum ASDs** are structural defects involving the **atrial septum** adjacent to the **AV valves** and are not amenable to spontaneous closure [1]. Their location near the **crux of the heart** and association with **cleft mitral valves** makes them more complex and less likely to resolve naturally compared to secundum ASDs. **Ostium primum ASDs** typically cause a **left axis deviation (LAD)** on the ECG due to an associated defect in the **atrioventricular (AV) conduction system**, leading to uncoordinated ventricular depolarization. **Right axis deviation (RAD)** is more commonly seen in **large secundum ASDs** with significant left-to-right shunting and resultant **pulmonary hypertension**. **Holt-Oram syndrome** is primarily associated with **secundum ASDs**, not ostium primum ASDs. Genetic or chromosomal abnormalities, such as Down's syndrome, are also known to cause septal defects [2]. **Ostium primum ASDs** account for about **15-20%** of all ASDs. **Secundum ASDs** are the most common type, typically involving the fossa ovalis, making up approximately **70-75%** of all atrial septal defects [1].

Q: Which is not a major criterion of Jones in rheumatic fever?

Elevated ESR. Elevated ESR - While an **elevated ESR** (erythrocyte sedimentation rate) is a common finding in acute rheumatic fever, it is considered a **minor criterion** in the modified Jones criteria due to its non-specificity. - Minor criteria include fever, arthralgia, elevated acute phase reactants (ESR, CRP), and prolonged PR interval on ECG. *Pancarditis* - **Pancarditis** (inflammation of all layers of the heart) is a **major criterion** and the most serious manifestation of rheumatic fever, as it can lead to permanent heart damage [1]. - It includes pericarditis, myocarditis, and endocarditis, often resulting in **valvulitis** [1]. *Arthritis* - **Arthritis**, typically a **migratory polyarthritis** affecting large joints, is a **major criterion** of Jones. - The pain is often disproportionately severe compared to the findings, hence the term "pain that flies from joint to joint." *Chorea* - **Sydenham's chorea** (St. Vitus' dance), characterized by rapid, purposeless involuntary movements, is a **major criterion** [1]. - It often appears later in the course of the disease and can be the sole manifestation of rheumatic fever [1].

Q: A lady presents with grade 3 dyspnea, severe mitral stenosis, and atrial fibrillation, with an increased ventricular rate and a clot in the left atrium. Which of the following should not be done?

Electrical cardioversion. ***Electrical cardioversion*** - Due to the presence of a **left atrial clot**, electrical cardioversion is contraindicated as it carries a high risk of **systemic embolism** if the clot dislodges. - Cardioversion should only be considered after **anticoagulation** and confirmation that no left atrial clot is present, typically via transesophageal echocardiography (TEE). *Rate control with diltiazem* - **Diltiazem** is a calcium channel blocker commonly used for **rate control in atrial fibrillation** by slowing AV nodal conduction [1]. - While rate control is important in this patient, especially with severe mitral stenosis, it does not directly address the immediate high risk of **embolism** from the clot [2]. *Warfarin therapy* - **Warfarin** is indicated for **anticoagulation** to prevent further clot formation and reduce the risk of embolism in patients with atrial fibrillation and a documented left atrial clot [2]. - However, warfarin itself will not acutely resolve an existing clot or address the immediate hemodynamic issues, and it requires a therapeutic INR before interventions like cardioversion can be considered. *Open mitral commissurotomy and removal of clot* - **Open mitral commissurotomy** is a surgical procedure to address severe mitral stenosis and can simultaneously allow for direct removal of a **left atrial clot**. - While this is a definitive treatment for both the stenosis and the clot, it is an invasive surgical option and not something to "not be done" if indicated, although risks need to be weighed.

Q: What is the best initial pharmacotherapy management option for a 30-year-old male who presents to the emergency department with palpitations, has a regular broad complex tachycardia on ECG, and is haemodynamically stable if DC cardioversion is not available?

IV procainamide. ***IV procainamide*** - **Procainamide** is a Class Ia antiarrhythmic drug and is an effective initial pharmacotherapy for **stable broad complex tachycardia (BCT)** if direct current cardioversion (DCC) is not immediately available - It works by blocking sodium and some potassium channels, prolonging the **action potential duration** and **effective refractory period**, which helps terminate re-entrant rhythms and slow conduction - Particularly useful when the origin of BCT (ventricular vs. supraventricular with aberrancy) is uncertain *IV amiodarone* - **Amiodarone** is a Class III antiarrhythmic drug that is effective for both supraventricular and ventricular arrhythmias - It is also an acceptable option for stable BCT and is preferred by some guidelines, though it has a **slower onset of action** compared to procainamide - May be preferred in patients with structural heart disease or heart failure *IV verapamil* - **Verapamil** is a non-dihydropyridine **calcium channel blocker** that primarily slows AV nodal conduction - It is **contraindicated** in broad complex tachycardia (BCT) of uncertain or ventricular origin because it can worsen hypotension and precipitate ventricular fibrillation - Can cause hemodynamic collapse in ventricular tachycardia or pre-excitation syndromes (e.g., Wolff-Parkinson-White syndrome) *IV adenosine* - **Adenosine** is primarily used for the acute termination of **supraventricular tachycardias (SVTs)**, especially those involving the AV node - It is **contraindicated** in broad complex tachycardia as it can lead to hemodynamic collapse or ventricular fibrillation, particularly if the BCT is due to **ventricular tachycardia** - May cause paradoxical acceleration in **Wolff-Parkinson-White syndrome** with antegrade conduction down an accessory pathway

Q: An old lady was brought to the emergency room in an unconscious state, with a history of previous similar attacks in the past months. An ECG was performed, and the resulting graph is shown below. Which of the following arrhythmias is the most probable cause?

2:1 Atrioventricular Block. ***2:1 Atrioventricular Block*** - The ECG shows a regular rhythm where every other **P wave** is not followed by a **QRS complex**, indicating a 2:1 ratio of P waves to QRS complexes. This is characteristic of a **2:1 AV block**. - The patient's history of recurrent unconsciousness and the bradycardia apparent in this rhythm (slow heart rate due to dropped beats) strongly suggest that this AV block is causing symptomatic **syncope**. *Paroxysmal Supraventricular Tachycardia (PSVT)* - PSVT is characterized by a **rapid heart rate** (typically 150-250 bpm) with narrow QRS complexes, which is contrary to the slow rate and dropped beats seen in the provided ECG. - While PSVT can cause syncope, the ECG pattern with regularly occurring P waves without subsequent QRS complexes is not consistent with PSVT. *Atrial Flutter* - **Atrial flutter** typically presents with a sawtooth pattern of **F waves** (flutter waves) in the baseline, particularly in leads II, III, and aVF, and a ventricular response that can be regular or irregular. - The ECG in question shows distinct P waves and dropped QRS complexes, not the characteristic flutter waves. *Ventricular Bigeminy* - **Ventricular bigeminy** involves a normal QRS complex followed by a premature ventricular contraction (PVC), and this pattern repeats. - The ECG does not show PVCs or such a repeating pattern; it clearly demonstrates regularly conducted beats alternating with non-conducted P waves.

Q: What is the best drug for managing atrial flutter with a 4:1 block?

Amiodarone. ***Amiodarone*** - **Amiodarone** is an effective antiarrhythmic drug for managing **atrial flutter** by controlling ventricular rate and potentially restoring sinus rhythm. - Its broad spectrum of action, including effects on potassium, sodium, and calcium channels, makes it suitable for various supraventricular and ventricular arrhythmias. *Esmolol* - **Esmolol** is a **beta-blocker** primarily used for rapid heart rate control in acute settings due to its short half-life. - While it can control ventricular rate in **atrial flutter**, it does not typically convert the rhythm to sinus [1]. *Vernakalant* - **Vernakalant** is an **antiarrhythmic drug** specifically approved for the rapid conversion of recent-onset atrial fibrillation to sinus rhythm. - It is not indicated for **atrial flutter** or for managing chronic arrhythmias. *Lignocaine* - **Lignocaine** (Lidocaine) is a **Class Ib antiarrhythmic drug** primarily used for **ventricular arrhythmias**. - It is generally ineffective for **supraventricular arrhythmias** like atrial flutter.

Q: Cardiac biomarker used for diagnosing reinfarction 8 days after initial ischemia is?

CK-MB. ***CK-MB*** - **CK-MB** (creatine kinase-MB) levels typically return to normal within **2-3 days** after an initial myocardial infarction, making it a suitable marker for detecting reinfarction several days later because its re-elevation would indicate new damage [2]. - Its relatively rapid normalization kinetics compared to troponins allows for better discrimination of new cardiac injury following the resolution of a prior event [2]. *Troponins* - **Cardiac troponins (I and T)** remain elevated for an extended period, typically **7-10 days** or even longer, after an acute myocardial infarction [3]. - Due to their prolonged elevation, troponins would likely still be elevated from the initial infarct 8 days prior, making it difficult to detect a reinfarction based solely on their levels [3]. *Myoglobin* - **Myoglobin** is one of the earliest markers to rise after myocardial injury but also has a very rapid clearance, returning to baseline within **24 hours**. - While sensitive for early detection, its short half-life makes it unsuitable for diagnosing reinfarction 8 days after initial ischemia, as any elevation would have resolved much earlier. *LDH* - **Lactate dehydrogenase (LDH)** is a late marker of myocardial infarction, rising within 24-48 hours and remaining elevated for up to **10-14 days** [1]. - Similar to troponins, the prolonged elevation of LDH from the initial infarct would obscure the detection of a reinfarction 8 days later [1].

Q: Which of the following is a characteristic feature of Takayasu arteritis?

Intimal fibrosis is a common finding.. ***Intimal fibrosis is a common finding.*** - **Intimal fibrosis** and thickening, along with **medial degeneration**, are characteristic pathological features seen in the affected arteries in Takayasu arteritis. - This fibrosis leads to **stenosis** and **occlusion** of large and medium-sized arteries, particularly the aorta and its main branches [1]. *Renal hypertension is a complication.* - While **renal hypertension** can occur in Takayasu arteritis due to **renal artery stenosis**, it is a *complication* of the disease process rather than a defining *characteristic pathological feature* of the vessel itself. - The fundamental characteristic is the inflammatory and fibrotic change in the arterial wall that *leads* to such complications [1]. *Coronary aneurysm can occur.* - **Coronary artery involvement**, including both **stenosis** and **aneurysm formation**, can occur in Takayasu arteritis. - However, similar to renal hypertension, a coronary aneurysm is a *potential manifestation* or complication, rather than the primary microscopic or macroscopic characteristic feature of the affected arterial pathology. *All of the options are features.* - While all listed options can be associated with Takayasu arteritis, only **intimal fibrosis** describes the characteristic *pathological change* within the arterial wall. - The other options describe complications or clinical manifestations that arise *from* this underlying pathological process.

Question 1

A healthy middle-aged man who became emotionally upset during an argument with his brother suddenly developed chest pain and collapsed. He was declared dead upon arrival at the hospital. What is the most likely diagnosis?

Accepted Answer

Takotsubo cardiomyopathy

Answer

Dilated cardiomyopathy

Answer

Chronic ischemic cardiomyopathy

Answer

Arrhythmogenic right ventricle dysplasia

Question 2

In which condition are epsilon waves observed on an ECG?

Accepted Answer

RV dysplasia

Answer

Hypothermia

Answer

Takotsubo cardiomyopathy

Answer

None of the options

Question 3

Which of the following is the most appropriate true statement regarding ostium primum atrial septal defect (ASD)?

Accepted Answer

Is unlikely to close spontaneously

Answer

Results in right axis deviation (RAD) on the ECG

Answer

Is associated with Holt-Oram syndrome

Answer

Is less common than secundum ASD

Question 4

Which is not a major criterion of Jones in rheumatic fever?

Accepted Answer

Elevated ESR

Answer

Pancarditis

Answer

Chorea

Answer

Arthritis

Question 5

A lady presents with grade 3 dyspnea, severe mitral stenosis, and atrial fibrillation, with an increased ventricular rate and a clot in the left atrium. Which of the following should not be done?

Accepted Answer

Electrical cardioversion

Answer

Rate control with diltiazem

Answer

Warfarin therapy

Answer

Open mitral commissurotomy and removal of clot

Question 6

What is the best initial pharmacotherapy management option for a 30-year-old male who presents to the emergency department with palpitations, has a regular broad complex tachycardia on ECG, and is haemodynamically stable if DC cardioversion is not available?

Accepted Answer

IV procainamide

Answer

IV verapamil

Answer

IV amiodarone

Answer

IV adenosine

Question 7

An old lady was brought to the emergency room in an unconscious state, with a history of previous similar attacks in the past months. An ECG was performed, and the resulting graph is shown below. Which of the following arrhythmias is the most probable cause?

Accepted Answer

2:1 Atrioventricular Block

Answer

Paroxysmal Supraventricular Tachycardia (PSVT)

Answer

Atrial Flutter

Answer

Ventricular Bigeminy

Question 8

What is the best drug for managing atrial flutter with a 4:1 block?

Accepted Answer

Amiodarone

Answer

Esmolol

Answer

Vernakalant

Answer

Lignocaine

Question 9

Cardiac biomarker used for diagnosing reinfarction 8 days after initial ischemia is?

Accepted Answer

CK-MB

Answer

Troponins

Answer

Myoglobin

Answer

LDH

Question 10

Which of the following is a characteristic feature of Takayasu arteritis?

Accepted Answer

Intimal fibrosis is a common finding.

Answer

Renal hypertension is a complication.

Answer

Coronary aneurysm can occur.

Answer

All of the options are features.

Cardiology — MCQs

Cardiology — MCQs

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