Cardiology Practice Questions

Q: Asynchronous cardioversion is given in:

Ventricular fibrillation. ***Ventricular fibrillation*** - **Asynchronous cardioversion** is also known as **defibrillation**, which means it delivers a shock randomly without synchronization to the cardiac cycle [1]. - **Ventricular fibrillation (VF)** is a chaotic rhythm with no discernible QRS complexes, thus synchronization is impossible and immediate defibrillation is life-saving [1], [2]. *AF* - **Atrial fibrillation (AF)** can be treated with **synchronized cardioversion** if it is unstable or persistent and requires rhythm control, as there are still discernible QRS complexes [3]. - Asynchronous cardioversion is generally not recommended for AF due to the risk of inducing **ventricular fibrillation** if the shock falls on the T-wave [2]. *Atrial flutter* - **Atrial flutter** with a rapid ventricular response is typically treated with **synchronized cardioversion** because the organized atrial activity allows for synchronization of the shock with the QRS complex [3]. - This minimizes the risk of delivering a shock during the vulnerable period of the T-wave, which could lead to more dangerous arrhythmias [2]. *Ventricular tachycardia* - **Ventricular tachycardia (VT)**, if stable and with a pulse, is treated with **synchronized cardioversion** to avoid delivering the shock during the vulnerable T-wave [2]. - If **pulseless VT**, it is treated as **ventricular fibrillation** (asynchronous defibrillation) due to the hemodynamic instability and immediate life threat [1].

Q: A female patient develops chest pain that is not associated with exercise, and chest auscultation shows multiple non-ejection clicks. The investigation used to diagnose the disease is:

Echocardiography for mitral valve prolapse. ***Echocardiography for mitral valve prolapse*** - **Non-ejection clicks** on auscultation are the classic physical finding for **mitral valve prolapse (MVP)**, often accompanied by a **mid-systolic click** and a late systolic murmur. - **Echocardiography** is the definitive diagnostic tool for MVP, allowing visualization of the mitral valve leaflets prolapsing into the left atrium during systole. *Pyrophosphate scan for cardiac amyloidosis* - A **pyrophosphate scan** is used to diagnose **transthyretin cardiac amyloidosis (ATTR-CM)**, which typically presents with heart failure symptoms and restrictive cardiomyopathy. - Cardiac amyloidosis does not typically manifest with isolated non-ejection clicks as its primary auscultatory finding. *ECG for heart rhythm evaluation* - An **ECG** evaluates the electrical activity of the heart for **arrhythmias** or evidence of ischemia or structural changes, such as hypertrophy. - While MVP can be associated with arrhythmias, an ECG alone cannot diagnose the structural abnormality of mitral valve prolapse or explain non-ejection clicks. *Thallium 201 scan for myocardial perfusion* - A **Thallium 201 scan** is a nuclear imaging test used to assess **myocardial perfusion** and detect areas of ischemia or infarction. - It is utilized for evaluating coronary artery disease and does not directly diagnose valvular abnormalities like mitral valve prolapse.

Q: In a patient with congenital prolonged QT syndrome presenting with intermittent torsades de pointes, which of the following is the first-line acute treatment?

Magnesium sulfate. ### Magnesium sulfate - **Magnesium sulfate** is the **first-line acute treatment** for **torsades de pointes (TdP)**, regardless of serum magnesium levels. - It helps stabilize the cardiac membrane, reducing ectopic activity and inhibiting triggered activity responsible for TdP. ### Beta-blockers - **Beta-blockers** are primarily used for **long-term management** of congenital **long QT syndrome** to prevent future episodes of TdP by reducing sympathetic tone and heart rate [2]. - They are **not** the immediate acute treatment for an ongoing TdP episode [2]. ### Isoprenaline for heart rate support - While sometimes used in specific forms of congenital LQTS, **isoprenaline** (or other beta-agonists) is generally **contraindicated** in TdP as it can worsen the arrhythmia by increasing heart rate and prolonging the QT interval [1]. - It might be considered in cases of **bradycardia-dependent TdP** but not as an initial general acute treatment [1]. ### Cardiac pacing if necessary - **Cardiac pacing** can be used in cases of **bradycardia-dependent TdP** where severe bradycardia is the trigger or in refractory cases that do not respond to magnesium. - It is **not** typically the **first-line acute treatment** but rather a secondary intervention.

Q: Radiofrequency ablation is commonly performed for which of the following conditions?

Paroxysmal supraventricular tachycardia (PSVT). ***Paroxysmal supraventricular tachycardia (PSVT)*** - **PSVT** is the most common indication for radiofrequency ablation, particularly **AV nodal reentrant tachycardia (AVNRT)**, which accounts for the majority of cases. - RFA has an extremely high success rate (>95%) for PSVT due to the **predictable anatomical circuits** involved, making it the first-line definitive treatment. *Ventricular tachycardia* - While RFA can treat certain types of **monomorphic VT**, it is typically reserved for **drug-refractory cases** or specific structural conditions like **right ventricular outflow tract VT**. - VT often arises from **complex scar tissue** in diseased ventricles, making ablation technically challenging with lower success rates compared to PSVT. *Atrial tachycardia* - **Focal atrial tachycardia** can be treated with RFA, but it represents a less common indication compared to PSVT due to **variable anatomical origins** within the atria. - Success rates are generally lower than PSVT because of the **multiple potential circuits** and difficulty in mapping the exact arrhythmogenic focus. *Wolff-Parkinson-White (WPW) syndrome* - **WPW syndrome** is an anatomical condition with an **accessory pathway** that predisposes to a specific type of PSVT called **AV reentrant tachycardia (AVRT)**. - When RFA is performed for WPW, it is essentially treating the **PSVT caused by the syndrome**, not the syndrome itself - making PSVT the more accurate answer for the arrhythmia being ablated.

Q: Which of the following is the primary feature of Eisenmenger syndrome?

Left-to-right shunt. ***Left-to-right shunt*** - Eisenmenger syndrome begins with a **left-to-right shunt** in congenital heart defects (e.g., VSD, ASD, PDA). This shunt leads to increased pulmonary blood flow and, eventually, **pulmonary hypertension**. [1] - Over time, the sustained pulmonary hypertension causes irreversible damage to the pulmonary vasculature, leading to a reversal of the shunt from left-to-right to **right-to-left**, resulting in cyanosis. [1] *Mitral stenosis* - This condition is a narrowing of the **mitral valve**, which obstructs blood flow from the left atrium to the left ventricle. - While it can cause pulmonary hypertension, it's not a primary feature or precursor to Eisenmenger syndrome, which is defined by an initial congenital shunt. *Atrial septal defect (ASD)* - An ASD is a type of **left-to-right shunt** that can *lead* to Eisenmenger syndrome, but it is not the primary feature *of* the syndrome itself. - The syndrome develops from the physiological consequences of the shunt (pulmonary hypertension and shunt reversal), not from the shunt's anatomical presence alone. [1] *Ventricular septal defect (VSD)* - A VSD is also a type of **left-to-right shunt** that can *cause* Eisenmenger syndrome, but it is the initial anatomical defect, not the primary physiological feature that defines the syndrome. - Eisenmenger syndrome represents the advanced stage where the VSD's hemodynamic impact has caused irreversible pulmonary vascular disease and shunt reversal. [1]

Q: ECG is poor in detecting ischemia in areas supplied by which of the following vessels?

Left Circumflex (LCx). ***Left Circumflex (LCx)*** - Ischemia in the area supplied by the **LCx artery** often occurs in the **posterior or lateral wall** of the left ventricle, which can be difficult to detect with standard 12-lead ECGs. - ECG leads that best view the LCx territory (V7-V9) are not routinely performed, leading to a higher chance of **silent or unrecognized ischemia**. *Left Anterior Descending (LAD)* - The LAD supplies the **anterior and septal walls** of the left ventricle, areas well-covered by standard ECG leads like V1-V4 [1][2]. - Ischemia in the LAD territory typically produces clear changes such as **ST-segment elevation** or **T-wave inversions** in these leads [2]. *Posterior Descending Artery (PDA)* - The PDA supplies the **inferior wall** and a portion of the posterior septum. - Ischemia in this area is generally well-detected by inferior leads (II, III, aVF) on a standard ECG, showing **ST-segment changes**. *Right Coronary Artery (RCA)* - The RCA typically supplies the **right ventricle** and, in most people, the **inferior wall** of the left ventricle via the PDA. - Ischemia due to RCA occlusion is usually visible in the **inferior leads** (II, III, aVF) and sometimes in **right precordial leads** (V3R, V4R) for right ventricular involvement.

Q: Which one of the following is a major criterion in Jones' criteria for rheumatic fever?

Sydenham's chorea. **Sydenham's chorea** - **Sydenham's chorea** is a neurological manifestation of rheumatic fever, characterized by **involuntary, jerky movements**, and is considered a major criterion [1]. - It results from inflammation of the **basal ganglia** and is unique to rheumatic fever among the acute manifestations [1]. *Carditis* - While **carditis** is a major criterion, it manifests as inflammation of the **heart muscle, valves, or pericardium** [1]. - This option is incorrect because Sydenham's chorea is also a major criterion and an example of one, making it a valid answer for the question. *Subcutaneous nodules* - **Subcutaneous nodules** are firm, painless nodules found over bony prominences. - They are considered a **minor criterion** in Jones' criteria for rheumatic fever. *High ESR* - **High ESR (Erythrocyte Sedimentation Rate)** is a non-specific inflammatory marker. - It is classified as a **minor criterion** in Jones' criteria, indicating general inflammation not unique to rheumatic fever.

Q: A 38-year-old daily laborer has a heart rate of 44 on routine examination. What is the most appropriate management?

Observation and no immediate treatment required. **Observation and no immediate treatment required** - The patient is a **daily laborer**, suggesting a physically demanding job which can lead to **physiologic bradycardia** due to increased vagal tone. - A heart rate of 44 bpm in an **asymptomatic individual** without other clinical signs of hypoperfusion (e.g., dizziness, lightheadedness, syncope) often requires no immediate intervention [1]. *Atropine* - Atropine is indicated for **symptomatic bradycardia** to increase heart rate by blocking the effects of the vagus nerve. - Since the patient is asymptomatic, there is no immediate indication for pharmacologic intervention with atropine. *Cardiac pacing* - **Temporary or permanent cardiac pacing** is reserved for severe symptomatic bradycardia or bradycardia unresponsive to medications, especially if associated with hemodynamic instability [1]. - An asymptomatic patient with a heart rate of 44 bpm does not meet the criteria for immediate pacing. *Adrenaline* - Adrenaline (epinephrine) is typically used in situations of **cardiac arrest** or profound symptomatic bradycardia unresponsive to atropine. - It is a potent vasoconstrictor and inotrope and is not a first-line agent for asymptomatic bradycardia.

Q: What is the treatment for acute cardiac tamponade?

Emergency pericardiocentesis. **Emergency pericardiocentesis** - **Emergent pericardiocentesis** is the definitive treatment for acute cardiac tamponade as it rapidly removes accumulated pericardial fluid, alleviating pressure on the heart [1]. - This procedure quickly restores cardiac filling and output, stabilizing the patient's hemodynamics [1]. *Emergency thoracotomy* - An **emergency thoracotomy** is a more invasive surgical procedure primarily used for severe chest trauma, such as massive hemorrhage or penetrating cardiac injuries. - While it can provide direct access to the heart, it is not the first-line treatment for acute cardiac tamponade where fluid drainage is the immediate priority. *Pericardiotomy* - **Pericardiotomy**, which involves surgically opening the pericardium, is typically performed in a more controlled operating room setting to treat chronic or recurrent pericardial effusions. - It is not a rapid, emergent procedure suitable for the acute, life-threatening nature of cardiac tamponade. *IV fluids* - While **IV fluids** might temporarily support blood pressure in patients with tamponade by increasing preload, they do not address the underlying problem of fluid compressing the heart. - Relying solely on IV fluids can delay definitive treatment and worsen the patient's condition by exacerbating the pericardial pressure.

Q: Ebstein's anomaly is associated with which of the following?

Right atrial enlargement. ***Right atrial enlargement*** - Ebstein's anomaly involves the **apical displacement** of the tricuspid valve leaflets into the right ventricle, effectively "atrializing" a portion of the right ventricle. - This creates a functional right atrium that is much larger than normal, leading to significant **right atrial enlargement** [1]. *Left atrial enlargement* - **Left atrial enlargement** is typically associated with conditions affecting the mitral valve or left ventricular function, such as mitral stenosis [3], mitral regurgitation, or diastolic dysfunction. - Ebstein's anomaly primarily affects the right side of the heart, with left atrial size usually being normal or secondarily affected by right heart failure. *Left ventricular enlargement* - **Left ventricular enlargement** (hypertrophy or dilation) is associated with conditions like aortic stenosis, aortic regurgitation [2], hypertension, or ischemic cardiomyopathy. - Ebstein's anomaly does not directly cause left ventricular enlargement. *Right ventricular enlargement* - Although a portion of the right ventricle is functional, the overall **right ventricular cavity is often reduced** or dysfunctional due to the displacement of the tricuspid valve. - The primary morphological change is the atrialization of the right ventricle and subsequent right atrial enlargement, rather than an increase in the size of the functional right ventricle.

Question 1

Asynchronous cardioversion is given in:

Accepted Answer

Ventricular fibrillation

Answer

AF

Answer

Atrial flutter

Answer

Ventricular tachycardia

Question 2

A female patient develops chest pain that is not associated with exercise, and chest auscultation shows multiple non-ejection clicks. The investigation used to diagnose the disease is:

Accepted Answer

Echocardiography for mitral valve prolapse

Answer

Pyrophosphate scan for cardiac amyloidosis

Answer

ECG for heart rhythm evaluation

Answer

Thallium 201 scan for myocardial perfusion

Question 3

In a patient with congenital prolonged QT syndrome presenting with intermittent torsades de pointes, which of the following is the first-line acute treatment?

Accepted Answer

Magnesium sulfate

Answer

Beta-blockers

Answer

Isoprenaline for heart rate support

Answer

Cardiac pacing if necessary

Question 4

Radiofrequency ablation is commonly performed for which of the following conditions?

Accepted Answer

Paroxysmal supraventricular tachycardia (PSVT)

Answer

Ventricular tachycardia

Answer

Atrial tachycardia

Answer

Wolff-Parkinson-White (WPW) syndrome

Question 5

Which of the following is the primary feature of Eisenmenger syndrome?

Accepted Answer

Left-to-right shunt

Answer

Mitral stenosis

Answer

Atrial septal defect (ASD)

Answer

Ventricular septal defect (VSD)

Question 6

ECG is poor in detecting ischemia in areas supplied by which of the following vessels?

Accepted Answer

Left Circumflex (LCx)

Answer

Left Anterior Descending (LAD)

Answer

Posterior Descending Artery (PDA)

Answer

Right Coronary Artery (RCA)

Question 7

Which one of the following is a major criterion in Jones' criteria for rheumatic fever?

Accepted Answer

Sydenham's chorea

Answer

Prolonged PR interval

Answer

High ESR

Answer

Fever

Question 8

A 38-year-old daily laborer has a heart rate of 44 on routine examination. What is the most appropriate management?

Accepted Answer

Observation and no immediate treatment required

Answer

Atropine

Answer

Cardiac pacing

Answer

Adrenaline

Question 9

What is the treatment for acute cardiac tamponade?

Accepted Answer

Emergency pericardiocentesis

Answer

Emergency thoracotomy

Answer

IV fluids

Answer

Pericardiotomy

Question 10

Ebstein's anomaly is associated with which of the following?

Accepted Answer

Right atrial enlargement

Answer

Left atrial enlargement

Answer

Left ventricular enlargement

Answer

Right ventricular enlargement

Cardiology — MCQs

Cardiology — MCQs

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