Cardiology Practice Questions

Q: Which of the following ECG features are characteristic of ventricular tachycardia?

Bizarre QRS complexes. ### Original Explanation ***Bizarre QRS complexes*** - In **ventricular tachycardia (VT)**, the electrical impulse originates from the ventricles, bypassing the normal conduction system [1]. - This leads to **aberrant ventricular activation**, resulting in **wide** and **unusual-looking QRS complexes** [1]. *Presence of AV dissociation [fusion beats]* - While **AV dissociation** can be present in VT, it is **not a universal characteristic** and is often seen in other wide complex tachycardias as well [1]. - **Fusion beats** are a specific type of AV dissociation where a ventricular and supraventricular impulse simultaneously activate the ventricles, which reinforces the diagnosis of VT; however, bizarre QRS complexes are a more direct visual indicator of ventricular origin [1]. *Prolonged duration of QRS complexes* - A prolonged QRS duration (typically **>0.12 seconds**) is characteristic of **wide complex tachycardias**, including VT [1]. - However, the term "bizarre" goes beyond simple prolongation to describe the **unusual morphology and irregular shapes** that are highly suggestive of a ventricular origin [1]. *P pulmonale* - **P pulmonale** refers to a **tall, peaked P wave** in leads II, III, and aVF, indicative of **right atrial enlargement**. - This finding is associated with conditions like **pulmonary hypertension** or **pulmonary embolism** and has no direct relevance to the diagnosis of ventricular tachycardia.

Q: Ejection click of pulmonary stenosis is better heard in

Inspiration. Inspiration - The **pulmonic ejection click** is associated with the opening of a **domed pulmonary valve** during systole [1]. - During **inspiration**, increased right ventricular filling causes more blood to be ejected, leading to earlier and louder opening of the stenotic pulmonary valve, making the click more prominent. Expiration - During **expiration**, venous return to the right side of the heart is reduced, decreasing right ventricular volume and making the pulmonic ejection click less noticeable or even absent. - This respiratory variation helps distinguish a pulmonic ejection click from an aortic ejection click, which does not vary with respiration [1]. Patient bending forward - **Bending forward** is a maneuver primarily used to accentuate **aortic regurgitation** murmurs, not to optimize the hearing of a pulmonic ejection click. - This position brings the heart closer to the chest wall, enhancing sounds originating from the left side of the heart. Patient lying in left lateral position - The **left lateral position** is commonly used to accentuate **mitral valve** sounds, such as the opening snap of mitral stenosis or the murmur of mitral regurgitation [1]. - This position does not specifically improve the audibility of a pulmonic ejection click.

Q: Levine sign is seen in

Acute Myocardial Infarction. ***Acute Myocardial Infarction*** - The **Levine sign** is a classic nonverbal gesture where a patient clenches their fist over the sternum, indicating **retrosternal chest pain** [1]. - This sign is highly suggestive of **ischemic chest pain**, often associated with an **acute myocardial infarction** [1]. *Pulmonary embolism* - Chest pain in pulmonary embolism is typically **pleuritic**, sharp, and localized, often worsened by breathing. - It does not usually present with the diffuse, constrictive quality expressed by the **Levine sign**. *Esophageal spasm* - Chest pain from esophageal spasm can mimic cardiac pain, but it is often described as a **squeezing or crushing sensation** behind the sternum and may be relieved by nitrates. - While it can be severe, it is less consistently associated with the **Levine sign** compared to myocardial infarction. *Aortic dissection* - The pain of aortic dissection is typically described as **sudden, severe, tearing, or ripping** and often radiates to the back. - It usually has a unique quality that is distinct from the constrictive pain signaled by the **Levine sign**.

Q: HOCM is common in which age group?

20 - 40 years. ***20 - 40 years*** - **Hypertrophic obstructive cardiomyopathy (HOCM)** is most commonly diagnosed in young to middle-aged adults, often presenting with symptoms during this age range [1]. - While it is a genetic condition present from birth, symptoms and diagnosis frequently occur in individuals who are **20 to 40 years old** [1]. *10 - 30 years* - While HOCM can manifest in adolescence, the peak incidence and symptomatic presentation typically extend into the 30s, making this range too narrow. - Many individuals in this group might be diagnosed during routine screenings or due to family history, but active symptom presentation often continues beyond 30 [1]. *30 - 50 years* - This age group is partially correct, but the onset often begins earlier, in the 20s. - Significant clinical manifestations and diagnoses are often made before the age of 30, making the 20-40 range more accurate for typical presentation. *40 - 60 years* - Although HOCM can persist and cause problems in older age, initial diagnoses and symptom onset are less common in this age group compared to younger adults [1]. - Patients diagnosed in this range often represent later presentations or milder forms that become symptomatic with aging [1].

Q: Which of the following is NOT a feature of aortic stenosis?

Pressure in the aorta is the same as in the left ventricle. ***Pressure in the aorta is the same as in the left ventricle*** - In **aortic stenosis**, there is a significant pressure gradient across the aortic valve during systole [2], meaning the **left ventricular pressure** is much higher than the **aortic pressure** to overcome the narrowed opening. - If the pressures were the same, it would indicate an unimpeded flow, suggesting the absence of significant stenosis. *Presence of ejection systolic murmur* - An **ejection systolic murmur** is a classic auscultatory finding in aortic stenosis, resulting from turbulent blood flow across the narrowed valve during systole [2]. [1] - This murmur is typically heard best at the **right upper sternal border** and radiates to the carotid arteries [2]. *Presence of pulsus tardus* - **Pulsus tardus** (or pulsus parvus et tardus) refers to a pulse that is weak (parvus) and delayed (tardus), which is characteristic of significant aortic stenosis [2]. - This occurs because the left ventricle ejects blood slowly and with reduced peak velocity into the aorta due to the **obstruction** at the valve. *Congestive heart failure* - **Congestive heart failure (CHF)** is a common complication of severe aortic stenosis. - The increased afterload on the left ventricle leads to **left ventricular hypertrophy** and eventual dysfunction, causing symptoms such as dyspnea, fatigue, and edema [1].

Q: Episode of stable angina pectoris typically lasts for

2 - 5 mins. ***2 - 5 mins*** - Episodes of **stable angina pectoris** are typically brief, lasting between 2 and 5 minutes [1]. - The chest discomfort is usually relieved by **rest** or sublingual **nitroglycerin** [1]. *Less than 1 min* - Anginal episodes usually last longer than 1 minute; very brief chest pain is often not typical for angina. - This duration might suggest a different etiology, potentially **musculoskeletal pain** or **esophageal spasm**. *5 - 10 mins* - While a single episode can sometimes last up to 10 minutes, this duration is at the upper limit for typical stable angina. - If pain persists for this long or longer, it raises suspicion for **unstable angina** or **myocardial infarction** [1]. *> 10 mins* - Chest pain lasting longer than 10 minutes is usually concerning for **unstable angina** or an **acute myocardial infarction** [1]. - It requires urgent medical evaluation to rule out more serious cardiac events.

Q: 38 yr old patient with high risk of coronary artery disease and hypertension, which of the following antihypertensive drugs will be suitable as a first line treatment for this patient?

ACE inhibitors. ### ACE inhibitors - **ACE inhibitors** are particularly suitable as first-line treatment for patients with hypertension and a high risk of **coronary artery disease (CAD)** because they have proven benefits in **cardiovascular protection** and **mortality reduction** [1]. - They improve **endothelial function** and can prevent **cardiac remodeling**, which is crucial in managing high-risk cardiovascular patients [4]. ### Calcium channel blockers - While effective for hypertension, **calcium channel blockers** do not offer the same level of **cardioprotection** in high-risk CAD patients as ACE inhibitors [1]. - They primarily act as **vasodilators** but lack the direct benefits on cardiac remodeling and atherosclerosis progression seen with ACE inhibitors. ### Beta-adrenergic blockers - **Beta-blockers** are generally not recommended as first-line monotherapy for essential hypertension unless there are specific compelling indications like **post-myocardial infarction** or **heart failure** [5]. - Their routine use as initial therapy for uncomplicated hypertension, especially in high-risk CAD patients without a recent event, is less favored compared to ACE inhibitors. ### Diuretics - **Diuretics**, particularly **thiazide diuretics**, are effective in lowering blood pressure and are often used, especially in elderly patients or those with salt sensitivity [3]. - However, for patients with high CAD risk, ACE inhibitors generally provide superior **cardiovascular benefit** beyond just blood pressure reduction, including preventing adverse cardiac events [2].

Q: What is the PRIMARY complication that requires lifelong management in patients with mechanical prosthetic heart valves?

Thromboembolism. ***Thromboembolism*** - Mechanical prosthetic heart valves are inherently **thrombogenic** due to non-endothelialized surfaces that interact with blood components, necessitating lifelong **anticoagulation** to prevent clot formation [2]. - Clots can form on the valve and embolize, leading to serious complications such as **stroke** or **peripheral arterial occlusion** [1]. *Immediate valve failure* - While possible, **immediate valve failure** is a rare event typically related to surgical error or a manufacturing defect and is not a primary, ongoing management concern. - The durability of modern mechanical valves is excellent, so failure generally occurs over a long period, if at all, due to structural degradation or infection, rather than immediately post-op. *Acute myocardial infarction* - **Acute myocardial infarction** is primarily caused by **coronary artery disease** and is not a direct complication of the prosthetic heart valve itself. - While valve surgery can be associated with cardiac complications, MI is not a unique, lifelong management issue specifically attributable to the presence of a mechanical valve. *Pulmonary edema* - **Pulmonary edema** can occur in the setting of heart failure due to severe valve dysfunction or other cardiac issues, but it is not a direct or primary complication of the mechanical valve itself requiring lifelong management unique to the valve. - Effective valve function, whether native or prosthetic, is aimed at *preventing* pulmonary edema, not causing it.

Q: Most frequent time period between myocardial infarction and subsequent myocardial rupture is -

3-4 days. ***3-4 days*** - This period corresponds to the peak of **macrophage infiltration** and **collagen degradation** in the infarcted myocardial tissue, making it most vulnerable. - The necrotic tissue is mechanically weak and susceptible to the **intracardiac pressure**, leading to rupture. *4-8 days* - By this stage, **scar formation** has usually begun, with fibroblasts appearing and laying down new collagen. - While still a vulnerable period, the initial peak of degradation and risk of rupture typically occurs earlier. *1-3 weeks* - During this time, significant **fibrosis and scar maturation** are occurring, leading to increased structural integrity of the infarct zone. - The risk of rupture significantly decreases as the **scar tissue** strengthens. *3-6 weeks* - At this point, the infarct is generally well-healed, with a dense **fibrous scar** largely replacing the necrotic tissue [1]. - The myocardial wall has regained considerable strength, making rupture highly unlikely at this late stage.

Q: What is commonly referred to as the widow's artery in myocardial infarction?

Left anterior descending artery. ***Left anterior descending artery*** - The **left anterior descending (LAD) artery** is often called the "widow maker" due to its critical role in supplying blood to a large area of the left ventricle, which is the heart's main pumping chamber [1]. - An **occlusion** in the LAD artery can lead to extensive damage, significantly increasing the risk of sudden cardiac death and making it a particularly dangerous site for a **myocardial infarction**. *Right coronary artery* - The **right coronary artery (RCA)** primarily supplies the **right ventricle**, the inferior wall of the left ventricle, and the SA/AV nodes. - While an RCA occlusion can cause a myocardial infarction, it is generally associated with a **better prognosis** and less extensive damage compared to an LAD occlusion. *Posterior interventricular artery* - The **posterior interventricular artery (PDA)**, also known as the posterior descending artery, typically branches off the RCA (in 85% of individuals) or the circumflex artery (in 15%) [2]. - It supplies the **diaphragmatic surface** of both ventricles and the posterior interventricular septum, but its occlusion is generally less critical than the LAD. *Left circumflex artery* - The **left circumflex artery (LCX)** supplies the lateral and posterior walls of the left ventricle [2]. - Although an LCX occlusion can lead to a significant myocardial infarction, it usually involves a **smaller territory** and is not as acutely life-threatening as an LAD occlusion.

Question 1

Which of the following ECG features are characteristic of ventricular tachycardia?

Accepted Answer

Bizarre QRS complexes

Answer

Presence of AV dissociation [fusion beats]

Answer

Prolonged duration of QRS complexes

Answer

P pulmonale

Question 2

Ejection click of pulmonary stenosis is better heard in

Accepted Answer

Inspiration

Answer

Patient bending forward

Answer

Patient lying in left lateral position

Answer

Expiration

Question 3

Levine sign is seen in

Accepted Answer

Acute Myocardial Infarction

Answer

Esophageal spasm

Answer

Aortic dissection

Answer

Pulmonary embolism

Question 4

HOCM is common in which age group?

Accepted Answer

20 - 40 years

Answer

10 - 30 years

Answer

30 - 50 years

Answer

40 - 60 years

Question 5

Which of the following is NOT a feature of aortic stenosis?

Accepted Answer

Pressure in the aorta is the same as in the left ventricle

Answer

Presence of pulsus tardus

Answer

Presence of ejection systolic murmur

Answer

Congestive heart failure

Question 6

Episode of stable angina pectoris typically lasts for

Accepted Answer

2 - 5 mins

Answer

Less than 1 min

Answer

5 - 10 mins

Answer

> 10 mins

Question 7

38 yr old patient with high risk of coronary artery disease and hypertension, which of the following antihypertensive drugs will be suitable as a first line treatment for this patient?

Accepted Answer

ACE inhibitors

Answer

Calcium channel blockers

Answer

Beta-adrenergic blockers

Answer

Diuretics

Question 8

What is the PRIMARY complication that requires lifelong management in patients with mechanical prosthetic heart valves?

Accepted Answer

Thromboembolism

Answer

Immediate valve failure

Answer

Pulmonary edema

Answer

Acute myocardial infarction

Question 9

Most frequent time period between myocardial infarction and subsequent myocardial rupture is -

Accepted Answer

3-4 days

Answer

4-8 days

Answer

1-3 weeks

Answer

3-6 weeks

Question 10

What is commonly referred to as the widow's artery in myocardial infarction?

Accepted Answer

Left anterior descending artery

Answer

Right coronary artery

Answer

Posterior interventricular artery

Answer

Left circumflex artery

Cardiology — MCQs

Cardiology — MCQs

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