Cardiology Practice Questions

Q: A 65-year-old woman with a history of atherosclerotic cardiovascular disease (ASCVD) presents with palpitations lasting 4 hours. Her heart rate is 180 beats per minute, blood pressure is 90/60 mmHg, and neck veins are distended. Auscultation reveals a carotid artery bruit, a loud S1, and a narrow split S2. Bilateral basal crepitations are noted on chest examination. Which of the following treatments is contraindicated for this patient?

Verapamil. ***Verapamil*** - Verapamil, a **non-dihydropyridine calcium channel blocker**, is contraindicated in patients with **wide-complex tachycardia**, especially if the origin is uncertain or suspected to be ventricular [2]. - Given the patient's **hypotension** and signs of **heart failure (distended neck veins, basal crepitations)**, verapamil could worsen her hemodynamic instability due to its negative inotropic and vasodilatory effects [1]. *Carotid sinus massage* - **Carotid sinus massage** can be attempted as a **vagal maneuver** to terminate supraventricular tachycardia (SVT), but it is contraindicated in patients with a **carotid bruit** due to the risk of dislodging an atherosclerotic plaque and causing a stroke [3]. - While typically a safe initial step for SVT, the presence of a carotid bruit in this patient raises concerns about underlying **carotid artery stenosis**, making this maneuver risky. *Face ice pack* - A **face-ice pack** is generally a safe and effective **vagal maneuver** for terminating stable supraventricular tachycardia (SVT), as it stimulates the diving reflex. - There are typically **no absolute contraindications** to its use in a hemodynamically unstable patient, but it may not be effective enough given the severity of the patient's symptoms. *Adenosine* - **Adenosine** is a treatment for **supraventricular tachycardia (SVT)**, although it should be used with caution in a hemodynamically unstable patient, particularly if there is doubt about the rhythm being true SVT. - While it can cause transient hypotension and bronchospasm, it is often a preferred treatment for SVT in unstable patients if the rhythm is clearly SVT and synchronized cardioversion is not immediately available or successful, as its effects are very short-lived.

Q: A case of severe mitral stenosis is associated with all of the following features, EXCEPT:

Opening snap delayed from S2. ***Opening snap delayed from S2*** - In severe mitral stenosis, the opening snap (OS) occurs **earlier** after S2 because the left atrial pressure (LA) is very high and rapidly exceeds the left ventricular pressure (LV), forcing the stiff mitral valve to open sooner. [1] - A **delayed opening snap** from S2 would suggest less severe mitral stenosis, as it takes longer for the LA pressure to overcome the LV pressure. [3] *Pulsatile liver* - This finding suggests **tricuspid regurgitation**, which can occur due to right heart failure secondary to severe pulmonary hypertension from long-standing severe mitral stenosis. [1] - The pulsatile liver is caused by retrograde flow through the incompetent tricuspid valve into the hepatic veins and inferior vena cava. *Atrial fibrillation* - Severe mitral stenosis often leads to significant **left atrial enlargement** and increased left atrial pressure, which are major predisposing factors for the development of atrial fibrillation. [1] - Atrial fibrillation further complicates mitral stenosis by reducing left ventricular filling and can lead to systemic embolization. [2] *Increase in the length of murmur* - A longer diastolic murmur in mitral stenosis indicates a longer duration of blood flow across the stenotic valve, which is characteristic of **more severe stenosis**. [1] - As the stenosis worsens, the pressure gradient across the mitral valve during diastole is sustained for a longer period.

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: Which score is calculated during the exercise tolerance test for assessing chronic stable angina?

Duke Score. ***Duke Score*** - The **Duke treadmill score** is a widely used prognostic tool in patients undergoing exercise stress testing for **chronic stable angina**, integrating exercise time, angina severity, and ST-segment deviation [1]. - It helps classify patients into **low, intermediate, or high-risk categories** for future cardiac events, guiding further management and diagnostic decisions [1]. *Bruce score* - The **Bruce protocol** is a common **treadmill exercise protocol** used for stress testing, where speed and incline are increased at 3-minute intervals [2]. - While it's the protocol used for the exercise, the derived **Bruce score** typically refers to the duration of exercise achieved, not a composite prognostic score like the Duke score [2]. *Jones Score* - The **Jones criteria** are primarily used for the diagnosis of **acute rheumatic fever**, based on major and minor manifestations. - This score is completely unrelated to cardiac stress testing or the assessment of angina. *DeBakey Score* - **DeBakey classification** is a system used to categorize **aortic dissections** based on their anatomical extent. - This score is relevant to aortic pathology and has no application in the context of exercise tolerance testing for stable angina.

Q: A 55-year-old woman with metastatic lung cancer presents with dyspnea and pedal edema. On examination, the jugular venous pressure is 10 cm, with a negative Kussmaul's sign. The heart sounds are diminished, and the lungs have bibasilar crackles. The electrocardiogram shows QRS complexes of variable height. For the patient with shortness of breath and peripheral edema, select the most likely diagnosis.

Cardiac tamponade. ***Cardiac tamponade*** - The combination of **dyspnea**, **pedal edema**, **elevated JVP** with a **negative Kussmaul's sign**, **diminished heart sounds**, and **electrical alternans** (QRS complexes of variable height) suggests cardiac tamponade [2]. - The patient's history of **metastatic lung cancer** increases the likelihood of **pericardial effusion**, which can lead to tamponade [2]. *Constrictive pericarditis* - This condition typically presents with a **positive Kussmaul's sign**, which is absent in this patient. - **Electrical alternans** is not a characteristic feature of constrictive pericarditis. *Restrictive cardiomyopathy* - While it can cause **dyspnea** and **edema**, it is not typically associated with **diminished heart sounds** or **electrical alternans**. - The primary defect is in **ventricular filling** due to myocardial stiffness, not external compression. *Right ventricle myocardial infarction (RVMI)* - RVMI causes right heart failure, leading to **elevated JVP** and **pedal edema**, but it does not cause **diminished heart sounds** or **electrical alternans** [1]. - It also usually presents with symptoms of **ischemia** and specific **ECG changes** (e.g., ST elevation in right precordial leads), which are not mentioned.

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.

Q: What is the threshold for defining a wide QRS duration?

> 0.12 sec. ***> 0.12 sec*** - A **QRS duration greater than 0.12 seconds** (or 120 milliseconds) is the standard definition for a wide QRS complex. - This indicates a delay in ventricular depolarization, often due to a **bundle branch block**, ventricular arrhythmia, or accessory pathway [1]. * 0.13 seconds would also be considered wide, the precise threshold that defines a wide QRS duration is **> 0.12 seconds**. - This option is less precise than the universally accepted cutoff. *> 0.10 sec* - A QRS duration greater than 0.10 seconds but not exceeding 0.12 seconds is typically considered a **borderline wide QRS** or an **incomplete bundle branch block**, not a fully wide QRS complex. - It does not meet the established criteria for a definitively wide QRS. *> 0.11 sec* - Similar to >0.10 sec, a QRS duration greater than 0.11 seconds but not exceeding 0.12 seconds is considered **borderline wide** or suggestive of mild conduction delay. - It falls just shy of the standard definition for a truly wide QRS.

Q: A patient with native aortic valve disease presents with right hemiparesis. What is the most appropriate management to prevent further stroke?

Start dual antiplatelet therapy. Start dual antiplatelet therapy - For patients with **native aortic valve disease** and cerebral ischemia, **dual antiplatelet therapy** is recommended to prevent future embolic events due to the increased risk of thrombus formation on the diseased valve surface [1]. - This approach aims to reduce platelet aggregation and subsequent clot formation, which is the primary mechanism of stroke in this context [1]. *Initiate intravenous anticoagulation* - **Intravenous anticoagulation** is generally reserved for acute ischemic stroke in the setting of atrial fibrillation [1] or in very specific circumstances where there is a high suspicion of a cardioembolic source not amenable to antiplatelets, but it carries a higher risk of hemorrhagic transformation in acute stroke. - In valvular heart disease, long-term anticoagulation is typically with warfarin for mechanical valves, and not usually initiated acutely for native valve disease with stroke. *Start warfarin therapy* - **Warfarin** is indicated for long-term anticoagulation in patients with **mechanical prosthetic heart valves** or in specific cases of native valve disease with atrial fibrillation, but it is not the primary choice for acute stroke prevention in native aortic valve disease without other indications. - Starting warfarin acutely requires careful monitoring and takes several days to achieve therapeutic levels, making it unsuitable for immediate stroke prevention. *Administer one dose of low molecular weight heparin* - A **single dose of low molecular weight heparin (LMWH)** is insufficient for effective long-term stroke prevention in the context of native aortic valve disease. - LMWH may be used in specific situations like bridging before warfarin or for VTE prophylaxis, but not as a primary strategy for preventing recurrent cardioembolic stroke from native valve disease.

Q: In which of the following conditions is a constant PR interval observed?

First degree AV block. ***First degree AV block*** - In **first-degree AV block**, every P wave is followed by a QRS complex, but the **PR interval** is consistently prolonged (usually > 0.20 seconds) [1]. - This simply indicates a **delayed conduction** through the AV node, not a missed beat or a variable PR interval [1]. *Third degree AV block* - Characterized by **complete AV dissociation**, where P waves and QRS complexes occur independently with no relationship between them. - The **PR interval is not constant** or even definable, as there is no consistent conduction from atria to ventricles. *Second degree AV block - Mobitz type I* - Also known as **Wenckebach phenomenon**, it shows a **progressive prolongation of the PR interval** until a QRS complex is dropped [1]. - Therefore, a constant PR interval is not observed; instead, it gradually lengthens over a few beats [1]. *Second degree AV block - Mobitz type II* - Involves **intermittent dropped QRS complexes** without prior PR interval prolongation [1]. - While the PR intervals of the conducted beats are constant, the **overall pattern is not one of a continuously constant PR interval** due to the dropped beats [1].

Q: A patient with low cardiac output is having a murmur of mitral regurgitation, and the CXR and histopathology of endomyocardial biopsy are shown. Which type of pulse would be present in this case?

Dicrotic pulse. ***Dicrotic pulse*** - A **dicrotic pulse** is characterized by two palpable waves per cardiac cycle, with the second wave occurring during **diastole** due to reflection from peripheral arterial beds. - This pulse is typically seen in conditions with **low cardiac output**, **decreased pulse pressure**, and **high systemic vascular resistance**, explaining its presence in this patient with low cardiac output and mitral regurgitation. *Anacrotic pulse* - An **anacrotic pulse** is characterized by a slow-rising carotid pulse with a palpable notch or shoulder on the ascending limb. - It is typically associated with conditions causing **left ventricular outflow obstruction**, such as **aortic stenosis**. *Pulsus bisferiens* - **Pulsus bisferiens** is a pulse with two distinct palpable systolic peaks. - This pulse is often found in patients with **aortic regurgitation** combined with **aortic stenosis** (mixed aortic valve disease). *Pulsus paradoxus* - **Pulsus paradoxus** refers to an abnormally large decrease in systolic blood pressure (>10 mmHg) during inspiration. - It is commonly associated with conditions causing extrinsic compression of the heart, such as **cardiac tamponade** or **severe asthma**.

Question 1

A 65-year-old woman with a history of atherosclerotic cardiovascular disease (ASCVD) presents with palpitations lasting 4 hours. Her heart rate is 180 beats per minute, blood pressure is 90/60 mmHg, and neck veins are distended. Auscultation reveals a carotid artery bruit, a loud S1, and a narrow split S2. Bilateral basal crepitations are noted on chest examination. Which of the following treatments is contraindicated for this patient?

Accepted Answer

Verapamil

Answer

Face ice pack

Answer

Adenosine

Answer

Carotid sinus massage

Question 2

A case of severe mitral stenosis is associated with all of the following features, EXCEPT:

Accepted Answer

Opening snap delayed from S2

Answer

Atrial fibrillation

Answer

Increase in the length of murmur

Answer

Pulsatile liver

Question 3

What is the treatment for acute cardiac tamponade?

Accepted Answer

Emergency pericardiocentesis

Answer

Emergency thoracotomy

Answer

IV fluids

Answer

Pericardiotomy

Question 4

Which score is calculated during the exercise tolerance test for assessing chronic stable angina?

Accepted Answer

Duke Score

Answer

Bruce score

Answer

Jones Score

Answer

DeBakey Score

Question 5

A 55-year-old woman with metastatic lung cancer presents with dyspnea and pedal edema. On examination, the jugular venous pressure is 10 cm, with a negative Kussmaul's sign. The heart sounds are diminished, and the lungs have bibasilar crackles. The electrocardiogram shows QRS complexes of variable height. For the patient with shortness of breath and peripheral edema, select the most likely diagnosis.

Accepted Answer

Cardiac tamponade

Answer

Constrictive pericarditis

Answer

Restrictive cardiomyopathy

Answer

Right ventricle myocardial infarction (RVMI)

Question 6

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

Question 7

What is the threshold for defining a wide QRS duration?

Accepted Answer

> 0.12 sec

Answer

> 0.13 sec

Answer

> 0.10 sec

Answer

> 0.11 sec

Question 8

A patient with native aortic valve disease presents with right hemiparesis. What is the most appropriate management to prevent further stroke?

Accepted Answer

Start dual antiplatelet therapy

Answer

Start warfarin therapy

Answer

Initiate intravenous anticoagulation

Answer

Administer one dose of low molecular weight heparin

Question 9

In which of the following conditions is a constant PR interval observed?

Accepted Answer

First degree AV block

Answer

Third degree AV block

Answer

Second degree AV block - Mobitz type I

Answer

Second degree AV block - Mobitz type II

Question 10

A patient with low cardiac output is having a murmur of mitral regurgitation, and the CXR and histopathology of endomyocardial biopsy are shown. Which type of pulse would be present in this case?

Accepted Answer

Dicrotic pulse

Answer

Anacrotic pulse

Answer

Pulsus bisferiens

Answer

Pulsus paradoxus

Cardiology — MCQs

Cardiology — MCQs

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