Cardiology Practice Questions

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: 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: 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 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: Straight back syndrome is associated with?

Mitral valve prolapse. ***Mitral valve prolapse*** - **Straight back syndrome** refers to a reduction in the normal thoracic kyphosis, which can decrease the **anteroposterior diameter** of the chest. - This flattened chest can compress the heart, particularly the **mitral valve**, leading to auscultatory findings suggestive of prolapse, even in the absence of true valvular dysfunction. *Ankylosing spondylitis* - This is a chronic inflammatory disease primarily affecting the **axial skeleton**, leading to spinal fusion and stiffness, which is distinct from a flattened thoracic spine. - While it affects the spine, it causes an abnormal **kyphosis or lordosis** rather than a simply straightened back that predisposes to cardiac compression. *Osteopetrosis* - This is a rare genetic disorder characterized by abnormally dense bones due to a defect in **osteoclast function**. - Its musculoskeletal manifestations involve increased bone fragility and hematological issues, not a specific spinal curvature anomaly like straight back syndrome. *Cor-triatriatum* - This is a rare congenital heart defect where the **left atrium (cor triatriatum sinistrum)** or, less commonly, the **right atrium (cor triatriatum dextrum)** is divided by a fibromuscular membrane. - It is a primary cardiac structural anomaly and has no association with musculoskeletal conditions such as straight back syndrome.

Question 1

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 2

Duration of pain in angina is:

Accepted Answer

2-5 mins

Answer

5-30 mins

Answer

30-60 mins

Answer

> 1 hour

Question 3

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 4

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 5

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 6

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

Accepted Answer

Elevated ESR

Answer

Pancarditis

Answer

Chorea

Answer

Arthritis

Question 7

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 8

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 9

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 10

Straight back syndrome is associated with?

Accepted Answer

Mitral valve prolapse

Answer

Osteopetrosis

Answer

Cor-triatriatum

Answer

Ankylosing spondylitis

Cardiology — MCQs

Cardiology — MCQs

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