Cardiology Practice Questions

Q: All the following are features of constrictive pericarditis except?

Acute pulmonary edema. **Explanation:** **Constrictive Pericarditis (CP)** is characterized by a rigid, non-compliant pericardium that limits diastolic filling of the heart [1]. The primary pathophysiology involves **dissociation of intrathoracic and intracardiac pressures** and **interventricular dependence**. **Why Acute Pulmonary Edema is the Correct Answer:** In CP, the rigid pericardium acts as a "shell" that limits the total cardiac volume. While filling is restricted, the **left atrial pressure rarely rises high enough** to cause acute pulmonary edema [2]. Furthermore, the right heart is equally affected, limiting the amount of blood pumped into the lungs. Acute pulmonary edema is a hallmark of left-sided heart failure or mitral valve disease, not typical CP. **Analysis of Incorrect Options:** * **Ascites:** CP presents with features of right-sided heart failure. Due to chronic systemic venous congestion, **ascites** is often disproportionately more severe than peripheral edema (pseudocirrhosis). * **Retractile Apex (Broadbent’s Sign):** The apex beat may be poorly felt or show systolic retraction because the heart is anchored to the rigid pericardium and diaphragm. * **Pericardial Knock:** This is a high-pitched early diastolic sound heard shortly after $S_2$. It occurs due to the sudden cessation of rapid ventricular filling by the rigid pericardium. **High-Yield Clinical Pearls for NEET-PG:** * **Kussmaul’s Sign:** Paradoxical rise in JVP during inspiration (Common in CP, absent in Cardiac Tamponade). * **Square Root Sign:** Seen on cardiac catheterization (dip-and-plateau pattern of ventricular pressure). * **Chest X-ray:** Pericardial calcification is a classic diagnostic clue [1]. * **Treatment:** Surgical pericardiectomy is the definitive management.

Q: Which of the following conditions exhibits increased murmur intensity upon standing?

Hypertrophic obstructive cardiomyopathy. ### Explanation The intensity of a cardiac murmur depends on the volume of blood flowing through the valve or the pressure gradient across an obstruction. [2] **1. Why HOCM is Correct:** Hypertrophic Obstructive Cardiomyopathy (HOCM) is unique because its murmur intensity is **inversely proportional** to the volume of the Left Ventricle (LV). When a patient stands, gravity causes venous pooling in the lower limbs, leading to **decreased venous return (preload)**. This reduces the LV end-diastolic volume. A smaller, "emptier" ventricle allows the hypertrophied septum and the mitral valve (SAM - Systolic Anterior Motion) to come closer together, worsening the outflow tract obstruction. [1] Increased obstruction leads to increased turbulence and a **louder murmur**. **2. Analysis of Incorrect Options:** * **Aortic Stenosis (AS):** Standing decreases preload, which reduces the stroke volume passing through the stenotic aortic valve. Less flow equals a **decreased** murmur intensity. [2], [3] * **Aortic Regurgitation (AR) & Mitral Stenosis (MS):** These are diastolic murmurs. Standing reduces the overall blood volume returning to the heart, thereby decreasing the pressure gradients and flow across these valves, leading to **decreased** murmur intensity. [4] **3. High-Yield Clinical Pearls for NEET-PG:** * **The "Rule of Two":** Only two murmurs become **louder** with standing or the Valsalva maneuver (both decrease preload): **HOCM** and **Mitral Valve Prolapse (MVP)**. * **Squatting/Handgrip:** These maneuvers increase preload/afterload and will **decrease** the intensity of HOCM and MVP murmurs while increasing most others (like AS or MR). * **HOCM Murmur:** It is a harsh systolic ejection murmur, best heard at the left sternal border (unlike AS, which radiates to the carotids).

Q: Which of the following is the earliest cardiac abnormality to develop in acute rheumatic fever?

Mitral regurgitation (MR). **Explanation:** In **Acute Rheumatic Fever (ARF)**, the cardiac involvement (pancarditis) primarily affects the endocardium, leading to valvulitis [2]. The **mitral valve** is the most common valve involved (followed by the aortic valve) [1]. **1. Why Mitral Regurgitation (MR) is correct:** During the acute phase of rheumatic fever, inflammation causes edema and thickening of the valve leaflets and chordae tendineae. This prevents the valve from closing properly during systole, leading to **Mitral Regurgitation** [1]. It is the hallmark clinical finding of acute rheumatic carditis and is often detected as a soft systolic murmur [2]. **2. Why the other options are incorrect:** * **Mitral Stenosis (MS):** This is a **chronic** manifestation of Rheumatic Heart Disease (RHD). It takes years (usually 5–20 years) for repeated inflammation, commissural fusion, and calcification to narrow the valve orifice. It is never seen in the acute phase. * **Aortic Regurgitation (AR):** While AR can occur in acute rheumatic fever, it is less common than MR and usually occurs in association with mitral valve disease, rather than in isolation. * **Aortic Stenosis (AS):** Similar to MS, AS is a chronic sequela resulting from progressive fibrosis and calcification. It is not an acute finding. **Clinical Pearls for NEET-PG:** * **Carey Coombs Murmur:** A short, mid-diastolic murmur heard at the apex in ARF due to active valvulitis (not to be confused with the murmur of MS). * **Order of Valve Involvement:** Mitral > Aortic > Tricuspid > Pulmonary (MATP). * **Aschoff Bodies:** The pathognomonic histological feature of rheumatic carditis. * **Jones Criteria:** Used for diagnosis [2]; Carditis is a major criterion.

Q: A 63-year-old woman presents with symptoms of palpitations and atrial flutter on the ECG. Which of the following is the most likely mechanism of this arrhythmia?

right atrial macro-reentry. **Explanation:** **1. Why Right Atrial Macro-reentry is Correct:** Atrial flutter is classically defined as a **macro-reentrant tachycardia** [1]. In the most common form (Typical Atrial Flutter), the electrical impulse travels in a large circuit around the **right atrium** [3]. This circuit typically involves the **cavotricuspid isthmus (CTI)**—a bridge of tissue between the inferior vena cava and the tricuspid valve—as a critical part of the pathway. This continuous looping results in the characteristic "sawtooth" pattern (F-waves) seen on an ECG, usually at an atrial rate of 250–350 bpm [3]. **2. Why the Other Options are Incorrect:** * **Atrial Asystole (A):** This refers to the absence of electrical and mechanical activity in the atria (flatline), which is the opposite of the rapid, organized activity seen in flutter. * **Atrial Bigeminy (B):** This is a rhythm where every normal sinus beat is followed by a premature atrial contraction (PAC). It is an ectopic phenomenon, not a macro-reentrant circuit. * **AV Nodal Reentry (D):** This is the mechanism for AVNRT (Atrioventricular Nodal Reentrant Tachycardia) [4]. While it is a reentrant rhythm, the circuit is localized within the **AV node** itself, not the atrial myocardium [4]. **3. NEET-PG High-Yield Pearls:** * **Typical Flutter:** Counter-clockwise reentry; shows negative sawtooth waves in leads II, III, and aVF [3]. * **Definitive Treatment:** Radiofrequency catheter ablation of the **cavotricuspid isthmus (CTI)** is the gold standard (high success rate) [2]. * **Drug of Choice for Rate Control:** Beta-blockers or Calcium Channel Blockers (Diltiazem/Verapamil) [2]. * **Anticoagulation:** Patients with atrial flutter require stroke risk assessment (CHA₂DS₂-VASc) similar to atrial fibrillation.

Q: A 70-year-old woman had an ECG at her annual checkup. Calculate her heart rate using the lead II recording.

70. ***70*** - Using the **large box method**: 300 ÷ number of large squares between R-R intervals gives approximately **70 bpm**, indicating a normal resting heart rate. - This rate is consistent with **normal sinus rhythm** in a healthy 70-year-old woman at rest during routine checkup. *92* - This rate would require **R-R interval spacing** of approximately **3.3 large boxes** (300 ÷ 92), which doesn't match the ECG tracing. - A heart rate of 92 bpm would indicate **mild sinus tachycardia**, which is not supported by the rhythm strip calculation. *84* - This corresponds to an **R-R interval** of approximately **3.6 large boxes** (300 ÷ 84), inconsistent with the actual measurement. - While 84 bpm falls within **upper normal range**, the mathematical calculation from the ECG doesn't support this value. *104* - This rate would require **R-R interval spacing** of approximately **2.9 large boxes** (300 ÷ 104), indicating **sinus tachycardia**. - A heart rate of 104 bpm would be **inappropriately elevated** for a resting ECG in an asymptomatic elderly patient.

Q: Intracavitary electrocardiography is a diagnostic aid in?

Ebstein's anomaly of the tricuspid valve. **Ebstein’s Anomaly** is characterized by the downward displacement of the septal and posterior leaflets of the tricuspid valve into the right ventricle. This results in the "atrialization" of the upper portion of the right ventricle. **Why it is the correct answer:** Intracavitary electrocardiography (ECG) is a classic diagnostic tool for Ebstein’s anomaly. When a catheter is passed across the displaced valve: * The **pressure tracing** shows a right ventricular (RV) waveform (high pressure). * The **intracavitary ECG** simultaneously records an atrial-like electrical signal (P-waves) because the electrode is technically in the "atrialized" portion of the ventricle. This dissociation—recording a ventricular pressure pulse alongside an atrial electrical potential—is pathognomonic for Ebstein’s anomaly. **Why other options are incorrect:** * **Tricuspid Regurgitation (A):** Diagnosis is primarily clinical (giant 'v' waves) and confirmed via Echocardiography (Doppler). Intracavitary ECG offers no specific diagnostic benefit here. * **Endocardial Fibroelastosis (B) & Endomyocardial Fibrosis (C):** These are restrictive cardiomyopathies. Diagnosis relies on imaging (MRI/Echo) and endomyocardial biopsy to identify fibrous thickening; intracavitary ECG does not show specific diagnostic patterns for these conditions. **High-Yield Clinical Pearls for NEET-PG:** * **ECG Findings:** "Himalayan" P-waves (tall/peaked), right bundle branch block (RBBB), and a short PR interval if Wolff-Parkinson-White (WPW) syndrome is present (associated in ~20% of cases). * **Auscultation:** Multiple heart sounds (split S1, S2, S3, and S4) creating a "sail sound" or "cadence" rhythm. * **X-ray:** Massive cardiomegaly with a "box-shaped" heart. * **Association:** Maternal intake of **Lithium** during pregnancy.

Q: Which of the following is NOT a cause of Pulseless Electrical Activity (PEA)?

Hydrogen ion depletion. Pulseless Electrical Activity (PEA) is a clinical condition where an organized cardiac rhythm is visible on the monitor, but there is no palpable pulse [1]. To identify the causes of PEA, clinicians use the high-yield **"5 Hs and 5 Ts"** mnemonic [1]. **Why "Hydrogen ion depletion" is the correct answer:** The correct reversible cause of PEA is **Hydrogen ion excess (Acidosis)**, not depletion [1]. Severe metabolic or respiratory acidosis leads to myocardial depression and decreased peripheral vascular resistance, triggering PEA. Alkalosis (hydrogen ion depletion) is not a recognized primary cause of PEA in standard Advanced Cardiovascular Life Support (ACLS) protocols. **Analysis of Incorrect Options:** * **Low pO2 < 60 mm Hg (Hypoxia):** This is one of the "5 Hs." Severe hypoxia leads to myocardial ischemia and failure of the excitation-contraction coupling, resulting in PEA [1]. * **Hypokalemia:** Both Hypokalemia and Hyperkalemia are part of the "5 Hs." Electrolyte imbalances disrupt the resting membrane potential of myocytes, leading to electrical activity without mechanical output [2]. * **Hypovolemia:** This is the most common cause of PEA [1]. A lack of intravascular volume means there is insufficient preload for the heart to generate a stroke volume, even if the electrical conduction system is intact. **High-Yield Clinical Pearls for NEET-PG:** * **The 5 Hs:** Hypovolemia, Hypoxia, Hydrogen ion (Acidosis), Hypo/Hyperkalemia, Hypothermia [1]. * **The 5 Ts:** Tension pneumothorax, Tamponade (Cardiac), Toxins, Thrombosis (Pulmonary), Thrombosis (Coronary) [1]. * **Management:** PEA is a **non-shockable rhythm**. Management focuses on high-quality CPR, Epinephrine (1mg every 3–5 mins), and aggressively identifying and treating the underlying cause (the 5 Hs and 5 Ts) [1].

Q: What is the effect of beriberi on circulation?

Hyperdynamic circulation. Wet Beriberi, caused by a severe deficiency of Thiamine (Vitamin B1), leads to a classic state of high-output heart failure characterized by hyperdynamic circulation [1]. The underlying pathophysiology involves systemic peripheral vasodilation (decreased systemic vascular resistance) due to the accumulation of pyruvate and lactate, which act as local vasodilators. This results in an increased venous return to the heart, leading to an increased stroke volume and cardiac output [1]. Clinically, this manifests as a wide pulse pressure, bounding pulses [2], and warm extremities. Analysis of Incorrect Options: * B. Hypovolemic shock: Beriberi causes fluid retention and volume overload (edema) due to heart failure, the opposite of hypovolemia. * C. Bradycardia: Hyperdynamic states typically present with tachycardia to maintain the high cardiac output [1]. * D. Pulsus paradoxus: This is a sign of cardiac tamponade [3] or severe asthma/COPD, not high-output failure. High-Yield NEET-PG Pearls: * Dry Beriberi: Presents as symmetrical peripheral neuropathy (sensory and motor). * Wet Beriberi: Presents with high-output heart failure and edema. * Shoshin Beriberi: A fulminant, acute form of wet beriberi leading to rapid cardiovascular collapse and lactic acidosis. * Treatment: Immediate IV Thiamine. Always administer thiamine before glucose in malnourished patients to prevent precipitating Wernicke-Korsakoff syndrome.

Question 1

All the following are features of constrictive pericarditis except?

Accepted Answer

Acute pulmonary edema

Answer

Ascites

Answer

Retractile apex

Answer

Pericardial knock

Question 2

Which of the following conditions exhibits increased murmur intensity upon standing?

Accepted Answer

Hypertrophic obstructive cardiomyopathy

Answer

Aortic stenosis

Answer

Aortic regurgitation

Answer

Mitral stenosis

Question 3

Which of the following is the earliest cardiac abnormality to develop in acute rheumatic fever?

Accepted Answer

Mitral regurgitation (MR)

Answer

Mitral stenosis (MS)

Answer

Aortic regurgitation (AR)

Answer

Aortic stenosis (AS)

Question 4

A 63-year-old woman presents with symptoms of palpitations and atrial flutter on the ECG. Which of the following is the most likely mechanism of this arrhythmia?

Accepted Answer

right atrial macro-reentry

Answer

atrial asystole

Answer

atrial bigeminy

Answer

AV nodal reentry

Question 5

A 70-year-old woman had an ECG at her annual checkup. Calculate her heart rate using the lead II recording.

Accepted Answer

70

Answer

92

Answer

84

Answer

104

Question 6

Intracavitary electrocardiography is a diagnostic aid in?

Accepted Answer

Ebstein's anomaly of the tricuspid valve

Answer

Tricuspid regurgitation

Answer

Endocardial fibroelastosis

Answer

Endomyocardial fibrosis

Question 7

What medication is indicated for a 62-year-old hypertensive patient with high lipids and atherosclerosis?

Accepted Answer

Amlodipine

Answer

Low dose aspirin

Answer

Heparin

Answer

Digoxin

Question 8

A 47-year-old woman presents with new-onset transient right arm weakness and word-finding difficulty lasting 3 hours. She also experiences exertional dyspnea and had a syncopal event 1 month ago. Her medical history is remarkable only for 2 uneventful pregnancies, and she is not taking any medications. Physical examination reveals normal vital signs and no residual focal neurological deficits. The ECG and CT brain are normal, but an echocardiogram reveals a cardiac tumor in the left atrium, which is pedunculated and attached to the endocardium. Which of the following is the most likely cause of this lesion?

Accepted Answer

Myxoma

Answer

Sarcoma

Answer

Rhabdomyoma

Answer

Fibroma

Question 9

Which of the following is NOT a cause of Pulseless Electrical Activity (PEA)?

Accepted Answer

Hydrogen ion depletion

Answer

Low pO2 < 60 mm Hg

Answer

Hypokalemia

Answer

Hypovolemia

Question 10

What is the effect of beriberi on circulation?

Accepted Answer

Hyperdynamic circulation

Answer

Hypovolemic shock

Answer

Bradycardia

Answer

Pulsus paradoxus

Cardiology — MCQs

Cardiology — MCQs

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