Cardiology Practice Questions

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: 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: What does Harvey's sign indicate?

Indicates venous filling after emptying a vein. ***Indicates venous filling after emptying a vein*** - **Harvey's sign**, also known as the **Trendelenburg test (modified)** or **Brodie-Trendelenburg test**, assesses the competence of venous valves in the legs [1]. - It involves emptying the superficial veins by elevating the leg and then observing for rapid venous filling after the patient stands, indicating **venous reflux** due to incompetent valves [1]. *Transmitted pressure wave on coughing in an artery* - This description typically relates to signs of a **patent ductus arteriosus** (a thrill or murmur) or **aneurysms**, where a cough can transmit a palpable impulse. - It is not associated with Harvey's sign or the assessment of venous valve competency [1]. *Loss of hair from eyebrows* - **Madarosis**, specifically loss of hair from the outer third of the eyebrows, is a classic sign of **hypothyroidism** (also known as Hertoghe's sign). - This symptom is entirely unrelated to Harvey's sign, which is a clinical maneuver for evaluating venous function. *None of the options* - This option is incorrect because the second option accurately describes Harvey's sign (or a related clinical maneuver for assessing venous competence).

Q: Which of the following murmurs will increase with Valsalva?

HOCM. ***HOCM*** - The Valsalva maneuver decreases **preload** and **left ventricular volume**, which exacerbates the **left ventricular outflow tract obstruction** in hypertrophic obstructive cardiomyopathy (HOCM) [1], thereby **increasing the intensity of the murmur**. - Reduced ventricular volume causes the **interventricular septum** and **mitral valve leaflet** to come closer, increasing the obstruction. *Ventricular Septal Defect (VSD)* - The murmur of a VSD is typically **louder with increased systemic vascular resistance**, which Valsalva would tend to *reduce* initially. - A decrease in venous return and ventricular filling during Valsalva would generally **decrease the intensity** of a VSD murmur, as less blood flows through the defect. *Aortic Stenosis (AS)* - Valsalva decreases **preload** and **stroke volume**, leading to a **reduction in blood flow** across the stenotic aortic valve [3]. - This reduction in blood flow results in a **decreased intensity** of the aortic stenosis murmur. *Mitral Regurgitation (MR)* - The murmur of mitral regurgitation is primarily dependent on the pressure gradient between the left ventricle and left atrium, and the size of the regurgitant orifice [2]. - While Valsalva can transiently decrease preload and cardiac output, its effect on MR is typically **attenuation or no significant change**, not an increase, as it would generally *reduce* forward flow.

Q: Which drug is considered the first-line treatment for pain relief in myocardial infarction?

Morphine sulfate. **Morphine sulfate** - **Morphine sulfate** is considered the first-line opioid analgesic for pain relief in acute myocardial infarction (MI) due to its potent analgesic and anxiolytic effects [1]. - It helps reduce **myocardial oxygen demand** by causing vasodilation, thereby decreasing preload and afterload. *Pentazocine* - **Pentazocine** is an opioid agonist-antagonist that can increase **heart rate** and **blood pressure**, which is undesirable in an MI setting. - It should be avoided in acute MI due to its potential to worsen myocardial ischemia and increase oxygen demand. *Midazolam* - **Midazolam** is a benzodiazepine used for sedation and anxiolysis, but it is not a primary analgesic for acute pain. - While it can help with anxiety associated with MI, it does not directly relieve the **ischemic chest pain**. *Aspirin* - **Aspirin** is crucial in MI management for its **antiplatelet effects**, preventing thrombus formation and reducing mortality. - However, it provides minimal to no direct pain relief for the severe chest pain experienced during an MI, making it an adjunctive treatment, not a primary analgesic.

Q: A patient after myocardial infarction becomes pulseless and blood pressure crashes. Diagnosis is?

Ventricular fibrillation. ***Ventricular fibrillation*** - **Ventricular fibrillation (VF)** is a chaotic, disorganized electrical activity in the ventricles resulting in no effective cardiac output, leading to pulselessness and a rapid drop in blood pressure [1, 3]. - It is a common cause of sudden cardiac arrest in post-myocardial infarction patients due to myocardial ischemia and electrical instability [3]. *Monomorphic ventricular tachycardia* - **Monomorphic ventricular tachycardia (VT)** involves rapid, regular ventricular contractions, which may or may not cause hemodynamic instability, but it typically presents with discernable QRS complexes [4]. - While it can lead to hemodynamic collapse, the description of "pulseless" and "blood pressure crashing" suggests a more chaotic rhythm, often preceding or degenerating into VF [1]. *Bidirectional tachycardia* - **Bidirectional tachycardia** is a rare form of ventricular tachycardia characterized by a 180-degree alternating QRS axis from beat to beat, often seen in **digitalis toxicity**. - While it can be unstable, the presentation of pulselessness and blood pressure crash points more strongly towards the chaotic nature of ventricular fibrillation after an MI. *Polymorphic ventricular tachycardia* - **Polymorphic ventricular tachycardia (PVT)** is characterized by continuously changing QRS morphology, indicating multiple ventricular foci or variations in conduction pathways. - While PVT can cause severe hemodynamic compromise and lead to pulselessness (e.g., Torsades de Pointes), the immediate post-MI setting with pulselessness often rapidly deteriorates to ventricular fibrillation [2].

Q: Among the following components of cigarette smoke, which is most directly associated with an increased risk of coronary artery disease?

Carbon monoxide. ***Carbon monoxide*** - **Carbon monoxide (CO)** is the cigarette smoke component most directly associated with coronary artery disease through formation of **carboxyhemoglobin (COHb)** [1]. - CO has **200-250 times higher affinity** for hemoglobin than oxygen, significantly reducing **oxygen delivery** to the myocardium and causing **tissue hypoxia** [1], [3]. *Nicotine* - While nicotine has important cardiovascular effects including **vasoconstriction** and **increased heart rate**, its association with coronary artery disease is less direct than CO's immediate impact on oxygen delivery. [2] - Nicotine promotes **platelet aggregation** and **endothelial dysfunction**, but these effects are secondary to CO's direct impact on **myocardial oxygenation**. *Tar* - **Tar** contains numerous **carcinogens** and irritants primarily linked to **lung cancer** and **COPD**, with more indirect cardiovascular effects through systemic inflammation. - While it contributes to **oxidative stress**, its association with coronary artery disease is significantly less direct than CO's immediate hemodynamic effects. *Polycyclic aromatic hydrocarbons* - **PAHs** are potent **carcinogens** with indirect cardiovascular impact through **oxidative stress** and **inflammation**, but not directly affecting coronary circulation like CO. - Their primary toxicity involves **DNA damage** and **cellular mutagenesis**, making their coronary disease association largely indirect and chronic.

Q: Absolute contraindication to thrombolytic therapy is:

History of hemorrhagic stroke in past one year. **History of hemorrhagic stroke in past one year** - A **history of hemorrhagic stroke** is an **absolute contraindication** to thrombolytic therapy due to the significantly increased risk of recurrent and fatal intracranial hemorrhage. [1] - Thrombolytic agents dissolve clots, and in a vessel weakened by prior hemorrhage, this can lead to catastrophic re-bleeding. [1] *Pregnancy* - Pregnancy is generally considered a **relative contraindication** but not an absolute one, as the risk-benefit decision depends on the specific clinical scenario and urgent need for thrombolysis. - The primary concern is fetal exposure to radiation and the potential for maternal and fetal bleeding complications. *Patients on nitrates* - Being on nitrates has **no direct contraindication** to thrombolytic therapy. [2] - Nitrates are commonly used in cardiac patients for vasodilation and symptom relief, and their use does not increase the risk of hemorrhage from thrombolysis. [2] *Hypertension* - **Uncontrolled severe hypertension** (e.g., systolic BP >185 mmHg or diastolic BP >110 mmHg) is a relative contraindication to thrombolysis, as it increases the risk of intracranial hemorrhage. - However, isolated hypertension without other risk factors, or hypertension that can be controlled, is not an absolute contraindication.

Q: In which of the following conditions is left atrial enlargement least prominent?

Atrial septal defect. ***Atrial septal defect*** - In an **atrial septal defect (ASD)**, blood shunts from the left atrium (LA) to the right atrium (RA). [1] This flow **reduces the volume load on the LA**, meaning the left atrium does not directly experience a significant increase in pressure or volume. - While increased flow goes to the **right ventricle and pulmonary arteries**, the left atrium itself is spared from the overload that typically causes enlargement. [1] *Ventricular septal defect* - A **ventricular septal defect (VSD)** causes a left-to-right shunt at the ventricular level, increasing blood flow to the **pulmonary circulation** and subsequently back to the left atrium. - This **volume overload returning to the left atrium** leads to prominent left atrial enlargement. *Aortopulmonary window* - An **aortopulmonary window (APW)** results in a large left-to-right shunt from the aorta to the pulmonary artery, significantly increasing **pulmonary blood flow**. - This increased pulmonary flow returns to the left atrium, causing substantial **volume overload and prominent left atrial enlargement**. *Patent ductus arteriosus* - A **patent ductus arteriosus (PDA)** allows blood to shunt from the aorta to the pulmonary artery, leading to increased **pulmonary blood flow**. - This increased flow returns to the left atrium, leading to significant **volume overload and prominent left atrial enlargement**.

Q: A wide and notched P wave is typically seen in:

Mitral stenosis. ***Mitral stenosis*** - A **wide and notched P wave**, often referred to as **P mitrale**, is characteristic of left atrial enlargement, which is a common sequela of mitral stenosis [1]. - The delayed depolarization of the enlarged left atrium causes the P wave to become prolonged and often develops a bifid or notched appearance. *Cor pulmonale* - Cor pulmonale typically leads to **right atrial enlargement**, which can manifest as a **tall, peaked P wave** (P pulmonale), not a wide and notched one. - This condition is caused by chronic lung disease leading to pulmonary hypertension [2]. *COPD* - While **COPD** can lead to **cor pulmonale** and subsequent right atrial enlargement, the characteristic P wave change is **P pulmonale** (tall, peaked P wave), not a wide and notched P wave. - COPD primarily affects the lungs, leading to increased pulmonary vascular resistance over time. *Pulmonary embolism* - An acute **pulmonary embolism** can cause **acute right heart strain**, which might lead to right atrial enlargement or other changes like **S1Q3T3 pattern** on ECG. - However, it does not typically cause a **wide and notched P wave**; the P wave changes associated with right atrial strain are usually tall and peaked.

Question 1

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

Accepted Answer

CK-MB

Answer

Troponins

Answer

Myoglobin

Answer

LDH

Question 2

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

Accepted Answer

Amiodarone

Answer

Esmolol

Answer

Vernakalant

Answer

Lignocaine

Question 3

What does Harvey's sign indicate?

Accepted Answer

Indicates venous filling after emptying a vein

Answer

Transmitted pressure wave on coughing in an artery

Answer

Loss of hair from eyebrows

Answer

None of the options

Question 4

Which of the following murmurs will increase with Valsalva?

Accepted Answer

HOCM

Answer

Ventricular Septal Defect (VSD)

Answer

Aortic Stenosis (AS)

Answer

Mitral Regurgitation (MR)

Question 5

Which drug is considered the first-line treatment for pain relief in myocardial infarction?

Accepted Answer

Morphine sulfate

Answer

Pentazocine

Answer

Midazolam

Answer

Aspirin

Question 6

A patient after myocardial infarction becomes pulseless and blood pressure crashes. Diagnosis is?

Accepted Answer

Ventricular fibrillation

Answer

Bidirectional tachycardia

Answer

Polymorphic ventricular tachycardia

Answer

Monomorphic ventricular tachycardia

Question 7

Among the following components of cigarette smoke, which is most directly associated with an increased risk of coronary artery disease?

Accepted Answer

Carbon monoxide

Answer

Tar

Answer

Polycyclic aromatic hydrocarbons

Answer

Nicotine

Question 8

Absolute contraindication to thrombolytic therapy is:

Accepted Answer

History of hemorrhagic stroke in past one year

Answer

Patients on nitrates

Answer

Hypertension

Answer

Pregnancy

Question 9

In which of the following conditions is left atrial enlargement least prominent?

Accepted Answer

Atrial septal defect

Answer

Ventricular septal defect

Answer

Patent ductus arteriosus

Answer

Aortopulmonary window

Question 10

A wide and notched P wave is typically seen in:

Accepted Answer

Mitral stenosis

Answer

COPD

Answer

Cor pulmonale

Answer

Pulmonary embolism

Cardiology — MCQs

Cardiology — MCQs

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