Cardiology — MCQs

Cardiology Indian Medical PG Practice Questions and MCQs

Question 1661: What is the most common source of systemic emboli?

A. Cardiac thrombi (Correct Answer)
B. Varicose veins
C. Pulmonary embolism
D. Deep vein thrombosis

Explanation: **Cardiac thrombi** - **Cardiac thrombi**, particularly those forming in the left atrium in conditions like **atrial fibrillation** or on damaged heart valves, are the most frequent source of systemic emboli [2]. - These thrombi can dislodge and travel through the arterial system, causing **ischemia** in various organs such as the brain (**stroke**), limbs, or kidneys [2]. *Varicose veins* - While varicose veins are a common venous condition, they are not typically a source of systemic arterial emboli. - Thrombi in varicose veins are usually superficial and rarely lead to significant embolism, and if they do, they would typically travel to the lungs (pulmonary embolism), not the systemic arterial circulation. *Pulmonary embolism* - A **pulmonary embolism** occurs when an embolus (often from a DVT) travels to the lungs, blocking pulmonary arteries [3]. - This is an arterial event within the pulmonary circulation and not a source of systemic emboli in the arterial circulation that supplies organs like the brain or limbs. *Deep vein thrombosis* - **Deep vein thrombosis (DVT)** involves the formation of blood clots in deep veins, most commonly in the legs [1]. - While DVTs are the primary source of **pulmonary emboli**, they do not typically cause systemic arterial emboli unless there is a right-to-left shunt in the heart (paradoxical embolism).

Question 1662: Buerger's disease is associated with

A. Alcoholism
B. Smoking (Correct Answer)
C. Trauma
D. Cold environment

Explanation: ***Smoking*** - Buerger's disease, or **thromboangiitis obliterans**, is strongly associated with **cigarette smoking**, leading to vasculitis and ischemia. - The cessation of smoking often leads to significant improvement in symptoms and cessation of disease progression. *Cold environment* - While cold exposure can exacerbate **peripheral vascular conditions**, it is not a primary cause or association of Buerger's disease. - The disease is primarily linked to **vasculitis** due to smoking, not environmental factors. *Trauma* - Trauma can cause vascular injury but is not a recognized association with Buerger's disease. - This disease is characterized by **segmental vasculitis** primarily related to **tobacco exposure**. *Alcoholism* - Although **alcoholism** can lead to various health issues, it is not specifically linked to Buerger's disease. - The primary risk factor is **smoking**, with alcoholic effects on the vasculature differing from those in Buerger's.

Question 1663: Which of the following statements regarding the left parasternal lift are NOT true?

A. Synchronous with left ventricular apical impulse.
B. Starts in early systole.
C. Corresponds to 'V' wave in LA pressure curve.
D. All of the options (Correct Answer)

Explanation: *All of the options* - This question asks for statements that are **NOT true**, and all listed options contain inaccuracies regarding the timing and physiological correlates of a left parasternal lift. [2] - A left parasternal lift, or heave, is typically associated with **right ventricular hypertrophy** or dilation, reflecting right ventricular activity rather than direct left ventricular events. [2], [3] *Synchronous with left ventricular apical impulse.* - A left parasternal lift is a palpable impulse over the **right ventricle**, while the apical impulse primarily represents the **left ventricular apex**. [2] These are distinct and not synchronous in the manner implied. [1] - While both occur during systole, they represent different ventricular actions and locations, making their direct synchronicity in terms of representing the same event incorrect. [1] *Starts in early systole.* - A left parasternal lift reflecting **right ventricular systole** begins with isovolumetric contraction of the right ventricle, which is indeed in early systole. [1] - However, the overall premise of the question is to identify incorrect statements about a left parasternal lift; while this particular point about timing is generally correct for right ventricular contraction, its inclusion here is part of identifying the broader inaccuracies in the other options if they are considered in the context of what a left parasternal lift *is not*. *Corresponds to 'V' wave in LA pressure curve.* - The 'V' wave in the left atrial (LA) pressure curve represents **passive filling** of the left atrium during ventricular systole and subsequent atrial volume overload, not a direct mechanical event like a parasternal lift. - A left parasternal lift is a **palpable chest wall movement** due to right ventricular activity, unrelated to the 'V' wave of left atrial pressure. [2]

Question 1664: A 50-year-old man with a history of smoking, hypertension, and chronic exertional angina develops several daily episodes of chest pain at rest compatible with cardiac ischemia. The patient is hospitalized. All the following would be part of an appropriate management plan except one.

A. Intravenous heparin
B. Aspirin
C. Beta-blockers
D. Lidocaine (Correct Answer)

Explanation: ***Lidocaine*** - **Lidocaine** is an antiarrhythmic drug primarily used for the treatment of **ventricular arrhythmias**, particularly in the setting of acute myocardial infarction [3]. - It is not a standard component of initial management for **unstable angina** or **non-ST elevation myocardial infarction (NSTEMI)** in the absence of documented ventricular arrhythmias. *Intravenous heparin* - **Intravenous heparin** is critical in the management of unstable angina and NSTEMI to prevent further thrombus formation. - It works by potentiation of **antithrombin III**, which inhibits the activity of thrombin and factor Xa. *Aspirin* - **Aspirin** is an essential antiplatelet agent used immediately in patients with acute coronary syndromes [2]. - It inhibits **cyclooxygenase-1 (COX-1)**, reducing thromboxane A2 production and thus **platelet aggregation** [3]. *Beta-blockers* - **Beta-blockers** are indicated to reduce myocardial oxygen demand by decreasing heart rate, blood pressure, and myocardial contractility [1]. - They help to alleviate angina symptoms and improve outcomes in patients with acute coronary syndromes by balancing **myocardial oxygen supply and demand** [1].

Question 1665: Intracavitary electrocardiography is a diagnostic aid in which of the following conditions?

A. Tricuspid valve stenosis
B. Atrial septal defect
C. Ventricular septal defect
D. Ebstein's anomaly of the tricuspid valve (Correct Answer)

Explanation: ***Ebstein's anomaly of the tricuspid valve*** - Intracavitary electrocardiography (ECG) is particularly useful in distinguishing **Ebstein's anomaly** from other conditions due to its ability to localize the AV conduction tissue relative to the tricuspid valve. - In Ebstein's anomaly, the **atrialized right ventricle** can be identified by the presence of a ventricular electrogram atrialized segment, which helps characterize the extent of tricuspid valve displacement. *Tricuspid valve stenosis* - While tricuspid valve stenosis affects the right heart, its primary diagnosis is made through **echocardiography** to assess flow obstruction and valve morphology. - Intracavitary ECG is not a standard or primary diagnostic tool for characterizing the anatomical features or hemodynamic severity of **tricuspid stenosis**. *Atrial septal defect* - An **atrial septal defect (ASD)** is typically diagnosed by **echocardiography**, which directly visualizes the defect and assesses shunt size and direction. - Intracavitary ECG is not routinely used for localizing or diagnosing an ASD, as its role is more focused on cardiac conduction and chamber electrophysiology. *Ventricular septal defect* - A **ventricular septal defect (VSD)** is primarily diagnosed using **echocardiography**, which offers clear visualization of the defect location, size, and hemodynamic impact. - Although VSDs can affect ventricular electrophysiology, intracavitary ECG is not a primary diagnostic tool for identifying or characterizing a VSD itself.

Question 1666: A young basketball player with a height of 188 cm and an arm span of 197 cm has a diastolic murmur best heard in the second right intercostal space. The likely cause of the murmur is:

A. AS
B. AR (Correct Answer)
C. MR
D. Coarctation of the aorta

Explanation: **AR** - **Aortic regurgitation** (AR) often presents as a **diastolic murmur** [1] best heard at the **second right intercostal space**, especially in the context of an athletic individual with features suggestive of connective tissue disorder (increased arm span relative to height, potentially indicating **Marfanoid habitus**). - AR symptoms, such as the diastolic murmur, arise from blood flowing back into the **left ventricle** during diastole [1] due to an incompetent aortic valve [2]. *AS* - **Aortic stenosis** (AS) typically presents as a **systolic ejection murmur** best heard at the **second right intercostal space**, radiating to the carotids, significantly different from the described diastolic murmur. - While congenital bicuspid aortic valve can lead to AS and is common in athletes, the timing of the murmur (systolic vs. diastolic) rules out primary AS as the cause here. *Coarctation of the aorta* - **Coarctation of the aorta** does not typically cause a diastolic murmur in the second right intercostal space; it is more associated with blood pressure discrepancies between upper and lower extremities and a **systolic murmur** heard over the back or left infraclavicular area. - Although it can be seen in athletes, its clinical presentation (murmur location and timing, blood pressure findings) does not match the patient's presentation. *MR* - **Mitral regurgitation** (MR) results in a **holosystolic murmur** best heard at the **apex** and often radiating to the axilla, which is neither diastolic nor heard in the second right intercostal space. - The location and timing of the murmur described in the question are inconsistent with MR.

Question 1667: A 59-year-old man with severe myxomatous mitral regurgitation is asymptomatic, with a left ventricular ejection fraction of 45% and an end-systolic diameter index of 2.9 cm/m2. The most appropriate treatment is

A. Mitral valve repair or replacement (Correct Answer)
B. ACE inhibitor therapy
C. Digoxin and diuretic therapy
D. Observation without intervention

Explanation: ***Mitral valve repair or replacement*** - The patient has severe asymptomatic **myxomatous mitral regurgitation** with a **left ventricular ejection fraction (LVEF) of 45%** (below 60%) and an **end-systolic diameter index (ESDI) of 2.9 cm/m²** (approaching or exceeding 40 mm, which is a common absolute ESLD threshold). These are key indicators for surgical intervention. [1] - Severe mitral regurgitation, even in an asymptomatic patient, warrants intervention when there is evidence of **LV dysfunction or significant LV dilation**, as these predict worse outcomes with medical management alone. [1] *ACE inhibitor therapy* - While ACE inhibitors can be used in some patients with mitral regurgitation to reduce afterload, they are generally reserved for those with **symptomatic heart failure** or **contraindications to surgery**. - They are not considered definitive treatment for severe mitral regurgitation with objective signs of LV dysfunction or dilatation requiring surgical correction. *Digoxin and diuretic therapy* - **Digoxin** is primarily used for rate control in atrial fibrillation or in heart failure with reduced ejection fraction, but it does not address the underlying mechanical problem of severe mitral regurgitation. - **Diuretics** can help manage fluid overload and symptoms of heart failure, but they do not prevent or reverse the progressive ventricular dysfunction caused by severe regurgitation, and are insufficient as sole therapy in this scenario. *Observation without intervention* - **Asymptomatic severe mitral regurgitation can be observed** if the LVEF is preserved (typically >60%) and the LV dimensions are normal or very minimally dilated (e.g., end-systolic diameter <40 mm or ESDI <2.0 cm/m²). - However, this patient's **LVEF of 45%** and **ESDI of 2.9 cm/m²** indicate early LV dysfunction and remodeling, which are clear triggers for intervention to prevent irreversible myocardial damage. [1]

Question 1668: Pruning of pulmonary arteries is seen in

A. Chronic bronchitis
B. Pulmonary transplant
C. Pulmonary hypertension (Correct Answer)
D. Pulmonary infections

Explanation: ***Pulmonary hypertension*** - **Pruning of pulmonary arteries** refers to the visible reduction in the number and size of peripheral pulmonary arterial branches, which is a characteristic radiological sign of **pulmonary hypertension** [1]. - This phenomenon is caused by remodeling and obstruction of the small pulmonary arteries, leading to increased **pulmonary vascular resistance**. *Chronic bronchitis* - While chronic bronchitis can lead to **hypoxia** and eventually pulmonary hypertension, the direct and prominent radiological sign of **pulmonary artery pruning** is primarily associated with established pulmonary hypertension rather than specifically chronic bronchitis itself. - Chronic bronchitis primarily affects the **airways**, causing mucous hypersecretion and chronic cough, rather than direct arterial remodeling visible as pruning on imaging. *Pulmonary transplant* - A pulmonary transplant is a surgical procedure to replace diseased lungs and does not inherently cause **pruning of pulmonary arteries**. In fact, a successful transplant aims to restore normal pulmonary vasculature, though complications like **rejection** could secondarily affect vascular structures [2]. *Pulmonary infections* - Pulmonary infections primarily cause **inflammation**, consolidation, or cavitation within the lung parenchyma. - They do not typically lead to the widespread, chronic remodeling and visible **pruning of pulmonary arteries** seen in pulmonary hypertension.

Question 1669: A 60-year-old man is discharged after being observed in the hospital for 4 days following a myocardial infarction. He returns to his normal activities, which include sedentary work only. At this point in time following a myocardial infarction, there is a special danger of which of the following?

A. Formation of a blood clot in the heart (mural thrombosis)
B. Heart failure due to weak pumping (pump failure)
C. Life-threatening arrhythmias
D. Tearing of the heart muscle (myocardial rupture) (Correct Answer)

Explanation: ***Myocardial rupture*** - This is a critical complication that can occur within the first week after a myocardial infarction, particularly when the infarct tissue is still necrotic and weak [1]. - Risk is heightened after an initial myocardial infarction, especially in the setting of **large transmural infarcts**. *Arrhythmia* - While arrhythmias can occur after a myocardial infarction, they are more commonly related to the **immediate post-infarction** period rather than specifically after 4 days [2]. - The majority typically stabilize as the myocardium heals, although monitoring is still essential. *Myocardial (pump) failure* - This can develop but is generally a consequence of more extensive heart damage, rather than an immediate post-discharge concern. - The patient has been stabilized for 4 days, reducing the imminent threat of acute pump failure. *Mural thrombosis* - While mural thrombosis may develop later in the post-myocardial-infarction period [3], the acute risk after 4 days is less than with myocardial rupture. - It is typically a concern during rehabilitation and more associated with **stasis** and **chamber dilation** rather than immediate danger.

Question 1670: All of the following are features of a benign heart murmur except which of the following?

A. Mid systolic
B. Heard at the left sternal area
C. Soft
D. Radiating to the lower chest (Correct Answer)

Explanation: ***Radiating to the lower chest*** - Benign murmurs are typically **localized** and **do not radiate widely**, especially not to the lower chest. [1] - Radiation suggests a more significant flow disturbance and is often a feature of **pathological murmurs**, indicating conditions like **aortic stenosis** (radiating to the carotids) or **mitral regurgitation** (radiating to the axilla). [1] *Mid systolic* - Many benign murmurs are **mid-systolic**, often referred to as **ejection murmurs**, which are common due to normal blood flow turbulence. [1] - This timing is characteristic of functional murmurs arising from the **right ventricular outflow tract** or **aortic root**. *Heard at the left sternal area* - Benign murmurs are frequently heard at the **left sternal border**, particularly in the **pulmonic area (2nd and 3rd intercostal spaces)**, often due to flow across the pulmonic valve. [1] - This location is common for innocent murmurs, such as a **Still's murmur** in children. *Soft* - Benign murmurs are characterized by being **soft (grade I-II/VI)**, meaning they are barely audible or easily heard but without a thrill. [1] - A **loud murmur (grade III/VI or higher)**, especially with a palpable thrill, is more indicative of a **pathological condition**.

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Coronary Artery Disease and Angina

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Acute Coronary Syndromes

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Heart Failure

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Cardiac Arrhythmias

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Valvular Heart Diseases

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Cardiomyopathies

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Pericardial Diseases

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Congenital Heart Disease in Adults

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Hypertension and Hypertensive Emergencies

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Pulmonary Hypertension

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Non-invasive Cardiac Diagnostics

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Preventive Cardiology

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Cardiology — MCQs

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