Cardiology Practice Questions

Q: A previously healthy 58-year-old man is admitted to the hospital because of an acute inferior myocardial infarction. Within several hours, he becomes oliguric and hypotensive (blood pressure is 90/60 mmHg). Insertion of a pulmonary artery (Swan-Ganz) catheter reveals the following pressures: pulmonary capillary wedge pressure - 4 mmHg; pulmonary artery pressure - 22/4 mmHg; and mean right atrial pressure - 11 mmHg. How would this patient be best treated?

Fluids. ### Explanation This patient is presenting with **Right Ventricular Infarction (RVI)**, a common complication occurring in up to 40% of patients with acute inferior wall MI (supplied by the Right Coronary Artery) [1]. **1. Why Fluids are Correct:** The hemodynamic profile provided is classic for RVI: * **Low PCWP (4 mmHg):** Indicates low left-sided filling pressures (normal: 6–12 mmHg) [2]. * **Elevated Right Atrial Pressure (11 mmHg):** Indicates right heart failure [1]. * **Hypotension and Oliguria:** Signifies low cardiac output. In RVI, the right ventricle fails to pump blood into the pulmonary circulation, leading to decreased preload for the left ventricle. The RV becomes "preload dependent." **Intravenous fluid resuscitation** (normal saline boluses) is the first-line treatment to increase right-sided filling pressures, which helps push blood through the lungs into the left atrium to maintain cardiac output [3]. **2. Why Other Options are Incorrect:** * **Digoxin:** Has no role in the acute management of MI-related cardiogenic shock; its inotropic effect is too weak and slow. * **Dopamine:** While an inotrope, it should only be used if hypotension persists *after* adequate fluid loading [3]. Starting vasopressors in a volume-depleted state can worsen ischemia. * **IABP:** Used for refractory cardiogenic shock or mechanical complications (e.g., papillary muscle rupture). It is not the initial step for RVI. **3. Clinical Pearls for NEET-PG:** * **Triad of RVI:** Hypotension, clear lung fields (normal PCWP), and Elevated JVP (Kussmaul’s sign). * **ECG Diagnosis:** ST-elevation in lead **V4R** (most sensitive). * **Management Contraindication:** Avoid **Nitrates, Diuretics, and Morphine** in inferior MI with suspected RVI, as they decrease preload and can precipitate profound hypotension. * **Hemodynamic Hallmark:** High RA pressure with low-to-normal PCWP (RA:PCWP ratio > 0.8).

Q: Contractile dysfunction is a hallmark feature of which type of cardiomyopathy?

Dilated cardiomyopathy. **Explanation:** The hallmark of **Dilated Cardiomyopathy (DCM)** is **systolic dysfunction**, characterized by impaired myocardial contractility. In DCM, the heart muscle becomes thin and stretched (dilated), leading to an increased end-diastolic volume but a significantly reduced **Ejection Fraction (EF <40%)**. This "pump failure" occurs because the thinned ventricles cannot generate sufficient force to eject blood effectively. **Why the other options are incorrect:** * **Hypertrophic Cardiomyopathy (HCM):** This is primarily a **diastolic dysfunction** disorder. The ventricle is hypercontractile (high EF), but the thickened (hypertrophied) walls are stiff and cannot relax properly to fill with blood. * **Restrictive Cardiomyopathy (RCM):** This is also a **diastolic dysfunction** disorder. The ventricular walls are rigid (but not necessarily thickened), which impedes ventricular filling. Contractility (systolic function) usually remains normal until the very late stages. * **Infiltrative Cardiomyopathy:** This is a sub-type of Restrictive Cardiomyopathy (e.g., Amyloidosis, Sarcoidosis). It results in stiff heart walls due to the deposition of abnormal substances, primarily affecting filling rather than contraction. **High-Yield Clinical Pearls for NEET-PG:** * **DCM:** Most common type of cardiomyopathy. Causes include Alcohol, Coxsackie B virus (Myocarditis), Pregnancy (Peripartum), and drugs like Doxorubicin. * **HCM:** Most common cause of sudden cardiac death in young athletes; characterized by asymmetric septal hypertrophy and mutations in Sarcomere proteins (Beta-myosin heavy chain). * **RCM:** Often associated with **Kussmaul’s sign** (rise in JVP on inspiration). Amyloidosis is the most common infiltrative cause.

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: What condition is characterized by a wide and fixed splitting of the second heart sound?

Atrial septal defect (ASD). **Explanation:** The second heart sound (S2) consists of two components: **A2** (Aortic valve closure) and **P2** (Pulmonary valve closure). In a healthy individual, S2 splits during inspiration because decreased intrathoracic pressure increases venous return to the right heart, delaying P2. **Why ASD is the correct answer:** In an **Atrial Septal Defect (ASD)**, there is a continuous left-to-right shunt. This leads to a persistent volume overload of the right ventricle, delaying the closure of the pulmonary valve (wide splitting) [1]. The split is **fixed** because the respiratory variations in systemic venous return are compensated by reciprocal changes in the shunt volume across the ASD [1], [4]. Consequently, the volume of blood entering the right ventricle remains constant throughout the respiratory cycle, keeping the A2-P2 interval unchanged. **Analysis of Incorrect Options:** * **Ventricular Septal Defect (VSD):** Typically presents with a **wide but mobile** (not fixed) split S2 [2]. The delay in P2 is due to right ventricular volume overload, but it still varies with respiration. * **Aortic Stenosis:** Causes a **reversed (paradoxical) split**. A2 is delayed due to prolonged left ventricular ejection, occurring after P2. The split narrows during inspiration. * **Patent Ductus Arteriosus (PDA):** Usually presents with a continuous "machinery" murmur [3]. While it can cause a paradoxical split if the shunt is large (due to LV overload), it does not cause a fixed split. **High-Yield Clinical Pearls for NEET-PG:** * **ASD Murmur:** The murmur in ASD is a **midsystolic flow murmur** over the pulmonary area (due to increased flow across the pulmonary valve), NOT due to the flow across the defect itself [1], [4]. * **ECG Finding:** Look for **RSR' pattern** in V1 (incomplete RBBB) and right axis deviation (in Secundum ASD). * **Most Common Type:** Ostium Secundum is the most common type of ASD [1].

Q: Which of the following is NOT true about Dressler's syndrome?

It occurs within hours after myocardial infarction.. Dressler’s syndrome, also known as **Post-Myocardial Infarction Syndrome**, is an immune-mediated form of pericarditis. **Why Option A is the correct answer (False statement):** Dressler’s syndrome is a **late complication** of myocardial infarction (MI). It typically occurs **2 to 6 weeks** after the initial cardiac event. It is caused by an autoimmune reaction to neoantigens released from necrotic myocardial cells. In contrast, pericarditis occurring within the first 24–72 hours post-MI is known as "Early Post-Infarction Pericarditis," which is due to direct inflammatory extension from the infarcted tissue, not an autoimmune process. **Analysis of other options:** * **Option B (Recurrence):** Like many autoimmune conditions, Dressler’s syndrome can be chronic or relapsing; recurrence is a recognized clinical feature. * **Option C (Chest pain):** Pleuritic chest pain (characteristically relieved by sitting forward) is the most common presenting symptom, often accompanied by fever and a pericardial friction rub. * **Option D (Salicylates):** High-dose Aspirin (salicylates) or NSAIDs are the first-line treatment [1]. Colchicine is often added to reduce the risk of recurrence [1]. **NEET-PG High-Yield Pearls:** * **Triad:** Fever, pleuritic chest pain, and pericardial effusion. * **Pathophysiology:** Type IV hypersensitivity (delayed) or immune-complex deposition. * **ECG Findings:** Diffuse ST-segment elevation with PR-segment depression (standard pericarditis pattern) [1]. * **Avoidance:** Steroids should generally be avoided in the early post-MI period as they may interfere with myocardial healing and increase the risk of ventricular rupture.

Q: Myocardial abscess is most common in acute endocarditis caused by which organism?

Staphylococcus aureus. **Explanation:** The correct answer is **Staphylococcus aureus (Option D)**. **Why Staphylococcus aureus is correct:** Myocardial abscess formation is a complication of **Acute Infective Endocarditis (IE)**. *Staphylococcus aureus* is a highly virulent, pyogenic organism capable of causing rapid valvular destruction and invading adjacent cardiac structures. Because it produces various toxins and enzymes (like coagulase and hyaluronidase), it easily penetrates the endocardium into the myocardium, leading to perivalvular abscesses, conduction disturbances, and even cardiac perforation. It is the most common cause of IE in intravenous drug users (IVDU) and those with prosthetic valves. **Why the other options are incorrect:** * **Streptococcus viridans (A):** This is the most common cause of **Subacute IE**. It has low virulence and typically affects previously damaged valves. It causes slow, vegetating growth rather than aggressive tissue invasion or abscess formation. * **Enterococci (B):** While Enterococci can cause aggressive IE (often post-GU/GI procedures), they are less commonly associated with myocardial abscesses compared to the highly destructive *S. aureus*. * **Streptococcus pneumoniae (C):** Though it can cause a fulminant "Austrian Syndrome" (triad of pneumonia, meningitis, and endocarditis), it is a much rarer cause of IE and myocardial abscesses than *S. aureus*. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site for abscess:** The **Aortic valve** ring (periaortic area) is more prone to abscess formation than the mitral valve. * **Clinical Clue:** If a patient with IE develops a **new-onset conduction block** (prolonged PR interval or Bundle Branch Block) on ECG, suspect a **perivalvular/myocardial abscess** (extension into the septum). * **Gold Standard Investigation:** Transesophageal Echocardiography (TEE) is superior to TTE for detecting myocardial abscesses.

Q: Which of the following is least likely to cause constrictive pericarditis?

Acute rheumatic fever. **Explanation:** **Constrictive Pericarditis (CP)** is the result of chronic inflammation leading to a thickened, fibrotic, and often calcified pericardium that restricts diastolic filling. [1] **Why Acute Rheumatic Fever (ARF) is the correct answer:** While ARF classically causes **pancarditis** (endocarditis, myocarditis, and pericarditis), the pericarditis associated with it is typically fibrinous or serofibrinous. Crucially, it **rarely, if ever, progresses to chronic constriction**. It usually resolves without significant residual fibrosis of the pericardial layers. **Analysis of Incorrect Options:** * **Tuberculous Pericardial Effusion:** In developing countries like India, Tuberculosis remains the **most common cause** of constrictive pericarditis. [1] The chronic granulomatous inflammation frequently leads to massive thickening and calcification. * **Staphylococcal Effusion:** Purulent (bacterial) pericarditis, often caused by *S. aureus*, carries a high risk of progressing to constriction due to the intense inflammatory response and organization of pus. [2] * **Post-Cardiac Surgery:** This is an increasingly common cause in developed nations. Post-operative bleeding and inflammation (Post-pericardiotomy syndrome) can lead to adhesions and subsequent constriction. **NEET-PG High-Yield Pearls:** 1. **Most common cause (Global/Developed):** Idiopathic or Viral. 2. **Most common cause (India):** Tuberculosis. [1] 3. **Kussmaul’s Sign:** Paradoxical rise in JVP during inspiration (Classic finding in CP). 4. **Pericardial Knock:** A high-pitched sound heard in early diastole due to the sudden cessation of ventricular filling. 5. **Imaging:** Chest X-ray may show a "rim of calcification" around the heart; CT/MRI are gold standards for measuring pericardial thickness (>3mm).

Question 1

In atrial septal defect, what is the typical state of the aorta?

Accepted Answer

Normal

Answer

Small

Answer

Enlarged

Answer

Aneurysmal

Question 2

A previously healthy 58-year-old man is admitted to the hospital because of an acute inferior myocardial infarction. Within several hours, he becomes oliguric and hypotensive (blood pressure is 90/60 mmHg). Insertion of a pulmonary artery (Swan-Ganz) catheter reveals the following pressures: pulmonary capillary wedge pressure - 4 mmHg; pulmonary artery pressure - 22/4 mmHg; and mean right atrial pressure - 11 mmHg. How would this patient be best treated?

Accepted Answer

Fluids

Answer

Digoxin

Answer

Dopamine

Answer

Intra-aortic balloon counterpulsation

Question 3

Contractile dysfunction is a hallmark feature of which type of cardiomyopathy?

Accepted Answer

Dilated cardiomyopathy

Answer

Restrictive cardiomyopathy

Answer

Hypertrophic cardiomyopathy

Answer

Infiltrative cardiomyopathy

Question 4

Which of the following are predisposing factors for Coronary Artery Disease?

Accepted Answer

Homocysteinemia, increased fibrinogen, increased plasminogen activator inhibitors 1

Answer

Homocysteinemia, decreased Lipoprotein B, increased plasminogen activator inhibitors 1

Answer

decreased Lipoprotein B, increased fibrinogen, increased plasminogen activator inhibitors 1

Answer

increased fibrinogen, increased HDL, increased plasminogen activator inhibitors 1

Question 5

A 20-year-old patient presents with syncope. His ECG shows specific findings, and his elder brother died suddenly. A subsequent cardiac MRI revealed fibro-fatty changes in the RV myocardium. What is the most likely diagnosis for this patient?

Accepted Answer

Arrhythmogenic RV dysplasia

Answer

Hypertrophic obstructive Cardiomyopathy

Answer

Brugada syndrome

Answer

Tako-Tsubo Cardiomyopathy

Question 6

All the following are features of constrictive pericarditis except?

Accepted Answer

Acute pulmonary edema

Answer

Ascites

Answer

Retractile apex

Answer

Pericardial knock

Question 7

What condition is characterized by a wide and fixed splitting of the second heart sound?

Accepted Answer

Atrial septal defect (ASD)

Answer

Ventricular septal defect (VSD)

Answer

Aortic stenosis

Answer

Patent ductus arteriosus (PDA)

Question 8

Which of the following is NOT true about Dressler's syndrome?

Accepted Answer

It occurs within hours after myocardial infarction.

Answer

Recurrence may be seen.

Answer

Chest pain is common.

Answer

It responds well to salicylates.

Question 9

Myocardial abscess is most common in acute endocarditis caused by which organism?

Accepted Answer

Staphylococcus aureus

Answer

Streptococcus viridans

Answer

Enterococci

Answer

Streptococcus pneumoniae

Question 10

Which of the following is least likely to cause constrictive pericarditis?

Accepted Answer

Acute rheumatic fever

Answer

Tuberculous pericardial effusion

Answer

Staphylococcal effusion

Answer

Post cardiac surgery

Cardiology — MCQs

Cardiology — MCQs

On this page

Practice by Chapter

Want unlimited practice?