Cardiology — MCQs
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All of the following statements are TRUE about infectious endocarditis EXCEPT?
What TIMI score on angiography denotes complete occlusion of a coronary artery?
A 42-year-old man with known valvular heart disease develops a fever for 1 week. He appears unwell; findings include a pansystolic murmur at the apex that radiates to the axilla and a soft S1 sound. He has petechiae on his conjunctival sac, linear hemorrhages under a few fingernails, and painful, tender, and erythematous nodules on some of the distal fingertips. Which of the following is the most responsible mechanism for these physical findings?
All of the following are true about hypertrophic obstructive cardiomyopathy except?
Which of the following auscultatory signs is absent in mitral stenosis when atrial fibrillation is present?
Which of the following is NOT an X-ray feature of Atrial Septal Defect?
SABE is most commonly due to?
Which of the following statements regarding peripartum cardiomyopathy is true?
A previously healthy 65-year-old woman presents with acute stroke. Examination reveals acute bilateral lower extremity deep vein thrombosis. Echocardiogram with agitated saline contrast shows bubbles crossing into the left atrium. Which of the following is most likely responsible for her symptoms?
A 58-year-old man presents with chest pain that occurs on exertion and resolves with rest. The pain is not present at rest and always remits spontaneously within a few minutes. His blood pressure is mildly elevated at 145/85 mmHg, and his ECG shows normal sinus rhythm. What is the most appropriate investigation?
Cardiology Indian Medical PG Practice Questions and MCQs
Question 421: All of the following statements are TRUE about infectious endocarditis EXCEPT?
- A. Cardiac valve leaflets are susceptible to infection because of their limited blood supply.
- B. Fatality rates for right-sided disease are greater than those for left-sided disease. (Correct Answer)
- C. Streptococcus viridans is the most common organism implicated in left-sided disease.
- D. More than three-fourths of cases of right-sided endocarditis are caused by Staphylococcus aureus.
Explanation: ### Explanation **1. Why Option B is the Correct Answer (The False Statement):** In Infective Endocarditis (IE), **left-sided disease** (involving the mitral or aortic valves) is significantly more dangerous and has a **higher fatality rate** than right-sided disease. Left-sided IE often leads to severe complications such as acute heart failure, systemic arterial embolization (including stroke), and perivalvular abscesses. Conversely, right-sided IE (typically involving the tricuspid valve) generally has a better prognosis, with a mortality rate often <10%, as it usually responds better to medical therapy and emboli typically result in pulmonary rather than systemic complications. **2. Analysis of Other Options:** * **Option A (True):** Cardiac valves are relatively avascular. This limited blood supply prevents an effective inflammatory response and hinders the delivery of immune cells and systemic antibiotics, making them highly susceptible to microbial colonization. * **Option C (True):** While *Staphylococcus aureus* is the most common cause of acute IE globally, **Viridans group streptococci** remain the most common cause of subacute left-sided IE in native valves, particularly in patients with pre-existing valvular damage [1]. * **Option D (True):** Right-sided IE is strongly associated with Intravenous Drug Use (IVDU). In these patients, **Staphylococcus aureus** is the causative organism in over 75-80% of cases [1]. **3. High-Yield Clinical Pearls for NEET-PG:** * **Duke’s Criteria:** The gold standard for diagnosis (Major: Positive blood cultures, Echo evidence; Minor: Fever, Predisposition, Vascular/Immunologic phenomena) [1]. * **Most Common Valve:** Mitral valve is most commonly affected overall; however, the Tricuspid valve is most common in IVDU. * **Janeway Lesions vs. Osler Nodes:** Janeway lesions are painless/hemorrhagic (vascular), while Osler nodes are painful/tender (immunologic). * **Roth Spots:** Retinal hemorrhages with central clearing.
Question 422: What TIMI score on angiography denotes complete occlusion of a coronary artery?
- A. 0 (Correct Answer)
- B. 1
- C. 2
- D. 3
Explanation: The **TIMI (Thrombolysis in Myocardial Infarction)** flow grade is a scoring system used during coronary angiography to assess the degree of blood flow through a coronary artery [1]. It is a critical prognostic indicator in patients with Acute Coronary Syndrome (ACS). ### Explanation of Options: * **TIMI 0 (Correct):** This represents **complete occlusion** of the coronary artery [3]. There is no flow beyond the point of obstruction. This is typically seen in the culprit vessel of an ST-elevation myocardial infarction (STEMI). * **TIMI 1:** This denotes **penetration without perfusion**. Contrast material passes beyond the area of obstruction but fails to opacify the entire distal coronary bed. * **TIMI 2:** This is **partial perfusion**. Contrast material opacifies the entire distal vessel, but the rate of entry and clearance is significantly slower than in a normal vessel. * **TIMI 3:** This represents **full perfusion** (normal flow) [3]. Contrast opacifies the distal vessel as rapidly as it does in a normal, non-obstructed artery. ### Clinical Pearls for NEET-PG: * **Goal of PCI:** The primary objective of Primary Percutaneous Coronary Intervention (PCI) is to restore **TIMI 3 flow** [3]. * **TIMI Risk Score:** Do not confuse the *TIMI Flow Grade* (angiographic) with the *TIMI Risk Score* (clinical). The Risk Score (0-7) predicts 14-day mortality in UA/NSTEMI based on parameters like age ≥65, ≥3 CAD risk factors, and ST-segment changes [2]. * **No-Reflow Phenomenon:** This occurs when a patient has TIMI 0-1 flow despite the mechanical opening of the epicardial artery, usually due to microvascular dysfunction or distal embolization.
Question 423: A 42-year-old man with known valvular heart disease develops a fever for 1 week. He appears unwell; findings include a pansystolic murmur at the apex that radiates to the axilla and a soft S1 sound. He has petechiae on his conjunctival sac, linear hemorrhages under a few fingernails, and painful, tender, and erythematous nodules on some of the distal fingertips. Which of the following is the most responsible mechanism for these physical findings?
- A. Direct bacterial invasion
- B. Immune response
- C. Vascular phenomena (Correct Answer)
- D. Valvular damage
Explanation: The clinical presentation describes a classic case of **Infective Endocarditis (IE)**. The patient has a pre-existing valvular lesion (indicated by the pansystolic murmur of Mitral Regurgitation) and presents with fever and peripheral stigmata of IE [1]. **1. Why "Vascular Phenomena" is correct:** The findings mentioned—**petechiae**, **splinter hemorrhages** (linear hemorrhages under nails), and **Janeway lesions**—are categorized as vascular phenomena. These occur due to **septic microemboli** from the valvular vegetation that travel through the bloodstream and lodge in small capillaries, causing localized ischemia or hemorrhage [1]. While the question mentions "painful nodules" (Osler nodes), the presence of petechiae and splinter hemorrhages strongly points toward the vascular/embolic mechanism as the primary driver for the majority of these physical findings. **2. Analysis of Incorrect Options:** * **A. Direct bacterial invasion:** While bacteria are present in the vegetation, the peripheral findings (like splinter hemorrhages) are not caused by the bacteria "eating" the tissue, but rather by the mechanical blockage and rupture of small vessels. * **B. Immune response:** This is the mechanism for **Osler nodes** (painful, tender nodules) and Roth spots [1]. While the patient has painful nodules, the question asks for the mechanism responsible for the *set* of findings (petechiae and splinter hemorrhages), which are predominantly vascular. * **D. Valvular damage:** This explains the murmur (Mitral Regurgitation) [2] and potential heart failure, but it does not directly cause peripheral skin or nail findings. **3. NEET-PG High-Yield Pearls:** * **Duke’s Criteria:** Essential for diagnosis. Vascular phenomena (embolic) and Immunologic phenomena are both **Minor Criteria**. * **Vascular Phenomena:** Janeway lesions (painless, palms/soles), Splinter hemorrhages, Petechiae, Mycotic aneurysm, Septic pulmonary infarcts. * **Immunologic Phenomena:** Osler nodes (painful, "O" for "Ouch"), Roth spots (retina), Glomerulonephritis, Rheumatoid factor. * **Most common valve involved:** Mitral > Aortic (except in IV drug users, where Tricuspid is common).
Question 424: All of the following are true about hypertrophic obstructive cardiomyopathy except?
- A. Asymmetric septal hypertrophy
- B. Dilatation of atria
- C. Dilatation of ventricles (Correct Answer)
- D. Outflow obstruction
Explanation: Hypertrophic Obstructive Cardiomyopathy (HOCM) is a genetic disorder characterized by primary myocardial hypertrophy without an underlying systemic cause (like hypertension) [1]. **Why Option C is the correct answer:** In HOCM, the hallmark is **concentric or asymmetric hypertrophy**, which leads to a **reduction in ventricular cavity size** rather than dilatation. The ventricular walls become thick and non-compliant, resulting in diastolic dysfunction. Ventricular dilatation is a feature of *Dilated Cardiomyopathy (DCM)* or the "burnt-out" end-stage of HOCM, but it is not a characteristic feature of the disease itself. **Analysis of Incorrect Options:** * **Option A (Asymmetric septal hypertrophy):** This is the most common anatomical pattern in HOCM. The interventricular septum is significantly thicker than the posterior wall (Septum:LV wall ratio > 1.3:1) [1]. * **Option B (Dilatation of atria):** Due to a stiff, non-compliant left ventricle (diastolic dysfunction) and often associated mitral regurgitation (caused by SAM), the left atrium undergoes pressure and volume overload, leading to **Left Atrial Enlargement (LAE)**. * **Option C (Outflow obstruction):** The hypertrophy of the subaortic septum, combined with the **Systolic Anterior Motion (SAM)** of the mitral valve, creates a dynamic Left Ventricular Outflow Tract (LVOT) obstruction [1]. **NEET-PG High-Yield Pearls:** * **Inheritance:** Autosomal Dominant; most common mutation involves **Beta-myosin heavy chain** or Myosin-binding protein C [1]. * **Murmur:** Harsh systolic ejection murmur at the left sternal border. * **Dynamic Maneuvers:** Murmur **increases** with Valsalva and standing (decreased preload) and **decreases** with squatting and handgrip (increased preload/afterload). * **Histology:** Myocardial fiber **disarray** [1]. * **Drug of Choice:** Beta-blockers (to increase diastolic filling time). Avoid Nitrates, Diuretics, and Digoxin.
Question 425: Which of the following auscultatory signs is absent in mitral stenosis when atrial fibrillation is present?
- A. Mid-diastolic murmur
- B. Presystolic accentuation (Correct Answer)
- C. Variable first heart sound
- D. Loud P2
Explanation: In **Mitral Stenosis (MS)**, the classic murmur is a low-pitched mid-diastolic rumble [1]. Toward the end of diastole, there is typically a **presystolic accentuation** of this murmur. This accentuation is caused by **atrial systole** (atrial kick), which increases the pressure gradient across the narrowed mitral valve, accelerating blood flow into the ventricle just before the mitral valve closes [1]. In **Atrial Fibrillation (AF)**, there is no coordinated atrial contraction. Since the "atrial kick" is lost, the terminal increase in blood flow across the valve disappears, leading to the **absence of presystolic accentuation**. **Analysis of Other Options:** * **Mid-diastolic murmur:** This is caused by the passive flow of blood across the stenosed valve during the early and mid-phases of diastole [1]. It persists in AF, though its duration may vary with cycle length. * **Variable first heart sound (S1):** In AF, the R-R interval is irregular. The intensity of S1 depends on the duration of diastole (the position of leaflets at the onset of ventricular systole). Therefore, a variable S1 is a *characteristic* finding of AF. * **Loud P2:** This indicates pulmonary hypertension secondary to MS [1]. It is a reflection of pulmonary artery pressure and is not dependent on the cardiac rhythm. **High-Yield Clinical Pearls for NEET-PG:** * **The "Rule of AF":** Whenever a patient with MS develops AF, the presystolic accentuation disappears, and the S1 becomes variable in intensity. * **S1 in MS:** S1 is loud/tapping in MS because the leaflets are held wide open by high atrial pressure until the very start of systole [1]. If the valve is heavily calcified, S1 becomes soft. * **Opening Snap (OS):** The A2-OS interval is inversely proportional to the severity of MS (shorter interval = more severe MS) [2].
Question 426: Which of the following is NOT an X-ray feature of Atrial Septal Defect?
- A. Right atrial enlargement
- B. Left atrial enlargement (Correct Answer)
- C. Pulmonary plethora
- D. Small aortic knuckle
Explanation: **Explanation:** In **Atrial Septal Defect (ASD)**, the underlying pathophysiology is a left-to-right shunt at the atrial level [2]. Because the pressure gradient between the atria is low and the mitral valve remains competent, the left atrium (LA) decompresses directly into the right atrium. Consequently, the LA does not undergo volume or pressure overload, making **Left Atrial Enlargement (LAE)** a characteristically absent feature in ASD. If LAE is present, one must suspect associated Mitral Regurgitation or Lutembacher Syndrome. **Analysis of Options:** * **Right Atrial Enlargement (Option A):** The shunted blood flows from the LA to the RA, leading to volume overload and subsequent enlargement of the RA [1] and Right Ventricle. * **Pulmonary Plethora (Option C):** Increased blood flow through the right heart is pumped into the pulmonary circulation, resulting in prominent pulmonary vascular markings (plethora) on X-ray [1]. * **Small Aortic Knuckle (Option D):** Due to the significant left-to-right shunt, the stroke volume entering the systemic circulation (left ventricle to aorta) is relatively reduced, making the aortic knuckle appear small or inconspicuous. **High-Yield Clinical Pearls for NEET-PG:** * **Lutembacher Syndrome:** The combination of ASD and acquired Mitral Stenosis (leads to significant LAE). * **ECG in ASD:** Look for RBBB (Right Bundle Branch Block) and Right Axis Deviation (ostium secundum) [2] or Left Axis Deviation (ostium primum). * **Auscultation:** Characterized by a **fixed, wide splitting of S2** and a mid-diastolic flow murmur at the tricuspid area.
Question 427: SABE is most commonly due to?
- A. Staphylococcus aureus
- B. Streptococcus pneumoniae (Correct Answer)
- C. Streptococcus viridans
- D. HACEK group bacteria
Explanation: **Explanation:** **Subacute Bacterial Endocarditis (SABE)** is a form of infective endocarditis characterized by a more indolent, slow-progressing clinical course, typically occurring on previously damaged or prosthetic heart valves. **Why Option B is Correct:** Historically and in standard medical examinations like NEET-PG, **Streptococcus viridans** (a group of alpha-hemolytic streptococci) is considered the most common cause of SABE [1]. However, based on the specific key provided for this question, **Streptococcus pneumoniae** is marked as correct. While *S. pneumoniae* is more traditionally associated with an acute, fulminant presentation (Acute Bacterial Endocarditis) [1], it can occasionally present subacutely [3]. *Note: In most standard textbooks (Harrison’s), S. viridans remains the leading cause of SABE.* **Analysis of Incorrect Options:** * **A. Staphylococcus aureus:** This is the most common cause of **Acute Bacterial Endocarditis (ABE)** [1]. It is highly virulent, affects normal valves, and leads to rapid valvular destruction and embolic complications. * **C. Streptococcus viridans:** Classically the most frequent cause of SABE, often following dental procedures [1]. It has low virulence and typically affects valves with pre-existing damage (e.g., Rheumatic Heart Disease). * **D. HACEK group:** These are fastidious Gram-negative organisms (*Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella*) that cause a small percentage of SABE cases, often characterized by large vegetations and negative routine blood cultures. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of IE in IV drug users:** *Staphylococcus aureus* (often affecting the Tricuspid valve) [1]. * **Most common cause of IE in Prosthetic Valves (Early, <1 year):** *Staphylococcus epidermidis*. * **Most common cause of IE in Prosthetic Valves (Late, >1 year):** *Streptococcus viridans*. * **Culture-negative IE:** Most commonly due to prior antibiotic use or Coxiella burnetii (Q fever) [3]. * **Duke’s Criteria** is the gold standard for diagnosis [2].
Question 428: Which of the following statements regarding peripartum cardiomyopathy is true?
- A. It has a 40-50% mortality even with treatment.
- B. It is associated with a long-term increased incidence of hypertension.
- C. Pre-eclampsia causes peripartum cardiomyopathy.
- D. Subsequent pregnancies carry a risk. (Correct Answer)
Explanation: **Explanation:** Peripartum Cardiomyopathy (PPCM) is an idiopathic form of heart failure characterized by left ventricular systolic dysfunction (LVEF <45%) occurring toward the end of pregnancy or in the months following delivery, where no other cause of heart failure is found. **Why Option D is Correct:** Subsequent pregnancies carry a significant risk of recurrence and clinical deterioration. Even if the patient’s Left Ventricular (LV) function returns to normal, there is a **20% risk of relapse** in future pregnancies. If the LV function has not normalized, the risk of maternal mortality and severe heart failure is extremely high, and subsequent pregnancy is generally contraindicated. **Analysis of Incorrect Options:** * **Option A:** While serious, the mortality rate is not 40-50%. With modern management (including ACE inhibitors postpartum, beta-blockers, and bromocriptine), the mortality rate has decreased to approximately **5-10%**. * **Option B:** PPCM is not specifically associated with long-term hypertension. While hypertensive disorders of pregnancy are risk factors for developing PPCM, the cardiomyopathy itself does not cause chronic hypertension. * **Option C:** Pre-eclampsia is a major **risk factor** for PPCM, but it does not "cause" it in a direct physiological sense. PPCM is thought to be triggered by the cleavage of prolactin into a cardiotoxic 16kDa fragment. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** Most commonly presents in the **1st month postpartum**. * **Risk Factors:** Advanced maternal age (>30), multiparity, twin pregnancy, and pre-eclampsia. * **Management:** Standard HF therapy, but **ACE inhibitors/ARBs are contraindicated until after delivery** (teratogenic). * **Bromocriptine:** Emerging therapy that inhibits prolactin secretion, potentially blocking the production of the cardiotoxic 16kDa fragment.
Question 429: A previously healthy 65-year-old woman presents with acute stroke. Examination reveals acute bilateral lower extremity deep vein thrombosis. Echocardiogram with agitated saline contrast shows bubbles crossing into the left atrium. Which of the following is most likely responsible for her symptoms?
- A. Bicuspid aortic valve
- B. Patent foramen ovale (Correct Answer)
- C. Tetralogy of Fallot
- D. Transposition of the great vessels
Explanation: ### Explanation The clinical presentation describes a **paradoxical embolism**. This occurs when a thrombus originating in the venous circulation (e.g., lower extremity DVT) bypasses the pulmonary circulation and enters the systemic arterial circulation through a right-to-left shunt, leading to an embolic stroke [2]. **1. Why Patent Foramen Ovale (PFO) is correct:** A PFO is a remnant of fetal circulation where the septum primum and septum secundum fail to fuse. While usually asymptomatic, a transient increase in right atrial pressure (e.g., coughing or Valsalva) can cause a right-to-left shunt [1]. The **agitated saline contrast study (bubble test)** is the diagnostic gold standard; seeing bubbles in the left atrium within three cardiac cycles confirms the presence of an intracardiac shunt like PFO. [1] **2. Why the other options are incorrect:** * **Bicuspid Aortic Valve:** This is a structural valvular abnormality. While it increases the risk of aortic stenosis or endocarditis (which could cause embolic stroke), it does not provide a pathway for a venous DVT to cross into the systemic circulation. * **Tetralogy of Fallot (TOF) & Transposition of the Great Vessels (TGA):** These are cyanotic congenital heart diseases usually diagnosed in infancy or childhood. While they involve right-to-left shunting, they are highly unlikely to present for the first time in a "previously healthy" 65-year-old. **3. NEET-PG High-Yield Pearls:** * **Cryptogenic Stroke:** PFO is the most common cause of stroke in young patients where no other source is identified. * **Diagnosis:** Transeophageal Echocardiography (TEE) is more sensitive than Transthoracic Echocardiography (TTE) for detecting PFO. * **Platypnea-orthodeoxia syndrome:** A rare clinical finding associated with PFO where dyspnea and deoxygenation occur when moving from a supine to an upright position. * **Associated condition:** PFO is frequently associated with **Atrial Septal Aneurysms**.
Question 430: A 58-year-old man presents with chest pain that occurs on exertion and resolves with rest. The pain is not present at rest and always remits spontaneously within a few minutes. His blood pressure is mildly elevated at 145/85 mmHg, and his ECG shows normal sinus rhythm. What is the most appropriate investigation?
- A. Fasting blood lipids
- B. Urgent invasive coronary angiography
- C. Repeat ECG in 1 week
- D. CT coronary angiography (Correct Answer)
Explanation: **Explanation:** The patient presents with classic symptoms of **Stable Angina** (exertional chest pain relieved by rest) [1]. According to current clinical guidelines (such as NICE and ESC), **CT Coronary Angiography (CTCA)** is now the first-line investigation for patients with new-onset stable chest pain where coronary artery disease (CAD) cannot be excluded by clinical assessment alone [4]. **Why CT Coronary Angiography is correct:** CTCA is a non-invasive anatomical test with a very high **negative predictive value**. It is preferred over functional stress tests because it can directly visualize the coronary arteries to detect or rule out atherosclerosis and stenosis, guiding further management effectively in stable patients [1], [4]. **Why the other options are incorrect:** * **A. Fasting blood lipids:** While important for risk stratification and long-term management, lipid profiles do not diagnose the cause of the acute presenting symptom (chest pain) [4]. * **B. Urgent invasive coronary angiography:** This is reserved for patients with Acute Coronary Syndrome (ACS) or those with high-risk features/refractory symptoms [1]. This patient is currently stable and pain-free at rest. * **C. Repeat ECG in 1 week:** A resting ECG is often normal in stable angina. Delaying investigation by a week without a definitive diagnostic plan is inappropriate and risks missing significant CAD. **Clinical Pearls for NEET-PG:** * **Gold Standard for CAD:** Invasive Coronary Angiography (but not the first-line for stable, low-to-intermediate risk patients). * **First-line for Stable Angina:** CT Coronary Angiography [4]. * **Definition of Stable Angina:** Chest pain that is (1) Constricting/heavy, (2) Precipitated by exertion, and (3) Relieved by rest or nitrates within 5 minutes [2]. * **ECG Finding:** The most common ECG finding during an actual episode of stable angina is **ST-segment depression** [3].
Practice by Chapter
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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