Cardiology Practice Questions

Q: A systolic thrill in the left 2nd and 3rd intercostal space may be seen in all of the following conditions, except?

Ebstein's anomaly. A systolic thrill in the **left 2nd and 3rd intercostal spaces (ICS)** corresponds to the **pulmonary area**. A thrill is the palpable vibration of a loud murmur (typically Grade 4/6 or higher), indicating high-velocity or turbulent blood flow across the right ventricular outflow tract (RVOT) or the pulmonary valve. **Why Ebstein’s Anomaly is the Correct Answer:** In Ebstein’s anomaly, there is downward displacement of the tricuspid valve leaflets into the right ventricle. This leads to severe **Tricuspid Regurgitation (TR)**. The murmur of TR is best heard at the **lower left sternal border** (4th/5th ICS), not the pulmonary area [1]. Furthermore, the murmur in Ebstein’s is often soft despite significant pathology, and the RVOT flow is typically decreased, making a pulmonary area thrill highly unlikely. **Analysis of Incorrect Options:** * **Pulmonic Stenosis:** This is the classic cause of a systolic thrill in the left 2nd ICS due to high-velocity turbulent flow across a narrowed pulmonary valve. * **Subpulmonic VSD (Supracristal):** Unlike perimembranous VSDs (heard at the 4th ICS), subpulmonic VSDs are located just below the pulmonary valve. The shunt flow is directed into the RVOT, producing a thrill in the left 2nd/3rd ICS. * **Pink Tetralogy of Fallot (TOF):** In "Pink" TOF, the right-to-left shunt is minimal. The predominant finding is significant infundibular pulmonary stenosis, which creates loud turbulence and a palpable thrill in the pulmonary area. **High-Yield Clinical Pearls for NEET-PG:** * **Left 2nd ICS Thrill:** Pulmonic Stenosis, ASD (rarely, due to high flow), Subpulmonic VSD. * **Right 2nd ICS Thrill:** Aortic Stenosis. * **Left 4th ICS Thrill:** Ventricular Septal Defect (Maladie de Roger). * **Ebstein’s Anomaly Triad:** "Sail sign" on CXR (huge right atrium), multiple heart sounds (split S1, S2, S3, S4 - "bizarre rhythm"), and WPW syndrome association.

Q: All of the following are true about Right Ventricular Infarcts, except?

Orthopnea. Right Ventricular Infarction (RVI) typically presents as a syndrome of **isolated right-sided heart failure**. The pathophysiology involves a failure of the right ventricle to pump blood into the pulmonary circulation, leading to systemic venous congestion. **Why Orthopnea is the correct answer:** Orthopnea (shortness of breath when lying flat) is a hallmark symptom of **Left Ventricular (LV) failure** [1]. It occurs due to the redistribution of fluid from the lower extremities to the lungs, increasing pulmonary capillary wedge pressure (PCWP). In pure RVI, the lungs are usually "clear" because the failing right heart cannot pump enough blood into the pulmonary vasculature to cause congestion or edema. In fact, PCWP in RVI is typically low or normal. **Analysis of incorrect options (Features of RVI):** * **Hepatomegaly and Ascites:** These are results of systemic venous hypertension. When the RV fails, blood backs up into the Inferior Vena Cava (IVC), leading to hepatic congestion (congestive hepatomegaly) and eventually fluid leakage into the peritoneal cavity (ascites). * **Nocturia:** In the daytime, gravity causes fluid to pool in the legs. At night, when the patient lies flat, venous return increases, improving renal perfusion and leading to increased urine production [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of RVI:** Hypotension, Clear Lungs, and Elevated JVP (Kussmaul’s sign may be present). * **ECG Diagnosis:** ST-elevation in **V4R** (most sensitive lead) in the setting of an Inferior Wall MI. * **Management Contraindication:** Avoid **Nitrates, Diuretics, and Morphine**, as they decrease preload. RVI is "preload dependent." * **Treatment of Choice:** Aggressive **IV Fluid resuscitation** (Normal Saline) to maintain RV filling pressure.

Q: A 68-year-old woman presents to the emergency department complaining of chest pain for the past 30 minutes. The pain is retrosternal in location and it radiates to her neck. She has no history of cardiac conditions or similar episodes of chest discomfort, and her past medical history includes hypertension and dyslipidemia. On physical examination, she is diaphoretic and in moderate distress. The blood pressure is 150/90 mm Hg, the heart sounds are normal, and the lungs are clear on auscultation. The ECG is shown in Figure below. Which of the following mechanisms is the most likely cause of her condition?

Coronary plaque rupture. ***Coronary plaque rupture*** - The **acute onset** of severe chest pain with **retrosternal location** and radiation to the neck, along with **diaphoresis** and distress, is classic for **acute coronary syndrome (ACS)**. - **Coronary plaque rupture** with subsequent **thrombosis** is the most common pathophysiological mechanism underlying **ST-elevation myocardial infarction (STEMI)** and **non-STEMI**, which fits this clinical presentation. *Aortic inflammation* - **Aortitis** typically presents with **tearing chest pain** that radiates to the back, not the neck, and is often associated with **blood pressure differentials** between arms. - The pain is usually described as **sudden onset** and **ripping** in nature, which differs from the retrosternal chest pain described in this case. *Pericardial inflammation* - **Pericarditis** characteristically presents with **pleuritic chest pain** that worsens with inspiration and improves when sitting forward. - It typically shows **diffuse ST elevation** across multiple leads on ECG, unlike the pattern expected in acute coronary syndrome. *Vasculitis* - **Systemic vasculitis** affecting coronary arteries is rare and typically occurs in the context of **autoimmune conditions** like **polyarteritis nodosa** or **Kawasaki disease**. - It usually presents with **systemic symptoms** such as fever, weight loss, and multi-organ involvement, which are absent in this acute presentation.

Q: Antibiotic prophylaxis is mandatory before dental extraction in patients with which of the following cardiac conditions?

Congenital heart disease. ### Explanation The primary goal of antibiotic prophylaxis before dental procedures is to prevent **Infective Endocarditis (IE)**. Dental extractions cause transient bacteremia (commonly *Viridans group streptococci*), which can seed onto damaged endocardium or prosthetic material, leading to life-threatening infections. **Why Congenital Heart Disease (CHD) is correct:** According to the latest AHA/ACC and ESC guidelines, antibiotic prophylaxis is only indicated for "High-Risk" conditions [1]. **Congenital Heart Disease** falls into this category under specific circumstances [3]: 1. **Cyanotic CHD** that has not been repaired. 2. CHD repaired with **prosthetic material** (for the first 6 months post-procedure) [1]. 3. Repaired CHD with **residual defects** at or adjacent to the site of a prosthetic patch/device. 4. Patients with a prior history of IE or those with prosthetic heart valves [1]. **Why other options are incorrect:** * **A, B, and C (IHD, Hypertension, CCF):** While these are significant cardiovascular morbidities, they do not involve the structural valvular abnormalities or high-velocity turbulent flow required to create a substrate (vegetation) for bacterial attachment. Therefore, the risk of IE in these patients is not significantly higher than in the general population. [2] **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice:** Oral **Amoxicillin (2g)** given 30–60 minutes before the procedure. * **If Penicillin allergic:** Use Clindamycin (600mg), Cephalexin (2g), or Azithromycin/Clarithromycin (500mg). * **Procedures requiring prophylaxis:** Only those involving manipulation of gingival tissue, the periapical region of teeth, or perforation of the oral mucosa. * **Not recommended anymore:** Prophylaxis is no longer required for routine mitral valve prolapse (MVP) or simple bicuspid aortic valves unless other high-risk criteria are met [1].

Q: Which of the following murmurs increases with the Valsalva maneuver?

Hypertrophic obstructive cardiomyopathy (HOCM). ### Explanation The **Valsalva maneuver** (specifically the strain phase) increases intrathoracic pressure, which decreases venous return to the heart. This leads to a **reduction in Left Ventricular (LV) end-diastolic volume** (preload). **Why HOCM is the correct answer:** In Hypertrophic Obstructive Cardiomyopathy, the pathology involves an asymmetrical septal hypertrophy that obstructs the LV outflow tract (LVOT). When the LV volume decreases (as during Valsalva), the ventricular walls and the anterior leaflet of the mitral valve move closer together. This **worsens the outflow obstruction**, thereby increasing the intensity of the systolic murmur. **Why the other options are incorrect:** * **Mitral Stenosis (A):** Decreased venous return reduces the flow across the stenotic mitral valve, thereby **decreasing** the intensity of the diastolic rumble [1]. * **Mitral Regurgitation (C) & Aortic Stenosis (D):** Both are "flow-dependent" systolic murmurs [1]. A decrease in preload leads to a lower stroke volume and less blood being ejected through the valves, resulting in a **decreased** murmur intensity [2]. **High-Yield Clinical Pearls for NEET-PG:** * **The "Rule of Two":** Most murmurs *decrease* in intensity during the Valsalva maneuver and standing. The only two exceptions (which **increase**) are **HOCM** and **Mitral Valve Prolapse (MVP)**. * **Handgrip Exercise:** This increases afterload. It **decreases** the murmur of HOCM and AS but **increases** the murmur of MR, AR, and VSD. * **Squatting:** Increases both preload and afterload; it **decreases** the HOCM murmur (opposite of Valsalva). [1, 2, 3, 4, 5]

Q: Prolonged QT interval is not seen in which of the following conditions?

Hypercalcemia. **Explanation:** The QT interval on an ECG represents the total time for ventricular depolarization and repolarization. It is primarily influenced by the duration of the action potential. **Why Hypercalcemia is the correct answer:** In **Hypercalcemia**, the increased extracellular calcium levels shorten the phase 2 (plateau phase) of the cardiac action potential. This leads to faster repolarization, which manifests on the ECG as a **shortened QT interval**. In severe cases, the ST segment may be completely absent, with the T wave starting immediately after the QRS complex. **Analysis of incorrect options (Conditions that prolong QT):** * **Hypocalcemia (B):** Low calcium levels prolong phase 2 of the action potential, leading to a lengthened ST segment and a **prolonged QT interval**. * **Hypokalemia (A):** Low potassium levels delay repolarization and often lead to the appearance of prominent **U waves** [1]. While the "true" QT may be normal, the fusion of the T and U waves creates a "QU interval," which is clinically interpreted as a prolonged QT. * **Hypomagnesemia (C):** Magnesium is a cofactor for the Na+/K+-ATPase pump. Its deficiency impairs repolarization and is frequently associated with both hypokalemia and hypocalcemia, collectively leading to QT prolongation. **High-Yield Clinical Pearls for NEET-PG:** * **Formula:** The corrected QT (QTc) is calculated using **Bazett’s Formula**: $QTc = QT / \sqrt{RR}$. * **Torsades de Pointes:** Prolonged QT interval is the primary precursor for this life-threatening polymorphic ventricular tachycardia [2]. * **Drug-induced QT prolongation:** Common culprits include Class IA and III antiarrhythmics, Macrolides, Fluoroquinolones, and Antipsychotics (e.g., Haloperidol). * **Congenital Syndromes:** Romano-Ward (autosomal dominant, pure cardiac) and Jervell and Lange-Nielsen (autosomal recessive, associated with sensorineural deafness) [3].

Question 1

A systolic thrill in the left 2nd and 3rd intercostal space may be seen in all of the following conditions, except?

Accepted Answer

Ebstein's anomaly

Answer

Subpulmonic Ventricular Septal Defect (VSD)

Answer

Pulmonic stenosis

Answer

Pink Tetralogy of Fallot (TOF)

Question 2

All of the following are true about Right Ventricular Infarcts, except?

Accepted Answer

Orthopnea

Answer

Nocturia

Answer

Hepatomegaly

Answer

Ascites

Question 3

A 68-year-old woman presents to the emergency department complaining of chest pain for the past 30 minutes. The pain is retrosternal in location and it radiates to her neck. She has no history of cardiac conditions or similar episodes of chest discomfort, and her past medical history includes hypertension and dyslipidemia. On physical examination, she is diaphoretic and in moderate distress. The blood pressure is 150/90 mm Hg, the heart sounds are normal, and the lungs are clear on auscultation. The ECG is shown in Figure below. Which of the following mechanisms is the most likely cause of her condition?

Accepted Answer

Coronary plaque rupture

Answer

Aortic inflammation

Answer

Pericardial inflammation

Answer

Vasculitis

Question 4

Eight days after undergoing a hysterectomy, a 64-year-old woman complains of chest pain. After 12 hours, which test will most likely support the diagnosis of myocardial infarction?

Accepted Answer

Tc 99m pyrophosphate scintigraphy showing a "hot spot"

Answer

Serum glutamic oxaloacetic transaminase (SGOT) elevation

Answer

Increased sedimentation rate

Answer

Thallium 201 (Tl 201) scintigraphy showing a "hot spot"

Question 5

Antibiotic prophylaxis is mandatory before dental extraction in patients with which of the following cardiac conditions?

Accepted Answer

Congenital heart disease

Answer

Ischemic heart disease

Answer

Hypertension

Answer

Congestive cardiac failure

Question 6

True about coarctation of aorta?

Accepted Answer

Most common site is distal to the origin of the left subclavian artery

Answer

Most common age of presentation is at 15–20 years

Answer

Upper rib notching is due to erosion by dilated collateral vessels

Answer

Right ventricular hypertrophy

Question 7

Which of the following murmurs increases with the Valsalva maneuver?

Accepted Answer

Hypertrophic obstructive cardiomyopathy (HOCM)

Answer

Mitral stenosis

Answer

Mitral regurgitation

Answer

Aortic stenosis

Question 8

Sukhia Rani, a 16-year old girl, presents with non-pitting edema of recent onset affecting her right leg and no other symptoms. Which of the following statements is true regarding this patient?

Accepted Answer

A lymphangiogram will show hypoplasia of the lymphatics.

Answer

Prophylactic antibiotics are indicated.

Answer

Elastic stockings and diuretics will lead to a normal appearance of the limb.

Answer

A variety of operations will ultimately lead to a normal appearance of the limb.

Question 9

A 16-year-old male is referred for a physical examination before joining the football team. His elder brother died suddenly during football practice; no autopsy was performed. The patient has a loud systolic murmur on chest auscultation. Which of the following findings is inconsistent with hypertrophic cardiomyopathy?

Accepted Answer

Increase in murmur intensity during Valsalva maneuver or standing

Answer

A crescendo-decrescendo systolic murmur

Answer

Murmur radiating to the neck

Answer

Brisk carotid upstroke

Question 10

Prolonged QT interval is not seen in which of the following conditions?

Accepted Answer

Hypercalcemia

Answer

Hypokalemia

Answer

Hypocalcemia

Answer

Hypomagnesemia

Cardiology — MCQs

Cardiology — MCQs

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