Cardiology — MCQs
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A 42-year-old man presents with central, crushing chest pain that radiates to the jaw. The pain occurred while jogging and was alleviated with rest. The ECG is normal. What is the most likely diagnosis?
A 42-year-old man presents with dizziness on standing, and his systolic blood pressure falls by 50 mm Hg. Which of the following would be most appropriate?
Carcinoid syndrome produces valvular disease primarily involving which valves?
Which of the following is not an absolute contraindication for thrombolytic therapy in acute ST segment elevation myocardial infarction?
A female with a history of recurrent rheumatic fever is on prophylactic penicillin therapy. Which heart valve is least commonly affected in chronic rheumatic heart disease?
A 47-year-old woman presents with a one-week history of progressive shortness of breath, increasing pedal edema, weight loss, and low-grade fever. She has a 40-pack-year smoking history. Physical examination reveals a pulse of 138 bpm, respirations of 34/min, blood pressure of 100/88 mm Hg with a pulsus paradoxus of 22 mm. Pertinent findings include increased jugular venous distension, normal sinus rhythm with distant heart sounds, and an apex beat that is difficult to palpate. What is the most likely diagnosis?
Which artery is most commonly involved in Myocardial Infarction (MI)?
A 25-year-old man with congenital cyanotic heart disease presents to the emergency department with a history of headache. On examination, there is a systolic murmur best heard on the left side of the sternum in the fourth intercostal space. The second heart sound is not split. Temperature is 37.5°C. What is the most likely diagnosis?
All of the following are true about hypertrophic obstructive cardiomyopathy, except?
Which condition is characterized by a 'dancing carotid'?
Cardiology Indian Medical PG Practice Questions and MCQs
Question 531: A 42-year-old man presents with central, crushing chest pain that radiates to the jaw. The pain occurred while jogging and was alleviated with rest. The ECG is normal. What is the most likely diagnosis?
- A. Angina pectoris (Correct Answer)
- B. Acute Pericarditis
- C. STEMI
- D. NSTEMI
Explanation: ### Explanation **1. Why Angina Pectoris is Correct:** The clinical presentation is classic for **Stable Angina Pectoris**. The patient describes "crushing" substernal chest pain (Levine’s sign) triggered by physical exertion (jogging) and relieved by rest [1]. This pattern indicates a predictable mismatch between myocardial oxygen supply and demand, typically due to fixed atherosclerotic coronary artery stenosis [2]. In stable angina, the **ECG is characteristically normal at rest**, as ischemia is transient and occurs only during stress [1]. **2. Why the Other Options are Incorrect:** * **Acute Pericarditis:** This typically presents with pleuritic chest pain (sharp, worsened by deep inspiration) that is relieved by leaning forward [3]. The ECG would classically show diffuse ST-segment elevation (concave upwards) and PR-segment depression. * **STEMI (ST-Elevation Myocardial Infarction):** This involves complete coronary occlusion. The pain is usually prolonged (>20 mins), occurs at rest, and is not relieved by rest or nitroglycerin. The ECG would show diagnostic ST-segment elevation. * **NSTEMI (Non-ST-Elevation Myocardial Infarction):** While NSTEMI may have a normal or non-specific ECG (ST-depression or T-wave inversion), the pain typically occurs at rest or is increasing in intensity (crescendo). Most importantly, NSTEMI involves myocardial necrosis, whereas the prompt describes pain relieved by rest, pointing toward stable ischemia. **3. NEET-PG High-Yield Pearls:** * **Gold Standard Investigation:** Coronary Angiography (to visualize stenosis). * **First-line Non-invasive Test:** Exercise Tolerance Test (Treadmill Test/TMT) [4]. * **Medical Management:** "B-A-S-I-C" (Beta-blockers, Aspirin, Statins, ACE inhibitors, and sublingual Glyceryl Trinitrate for acute relief). * **Key Distinction:** If chest pain occurs at rest with a normal ECG, consider **Prinzmetal (Variant) Angina**, which is caused by coronary vasospasm rather than fixed obstruction.
Question 532: A 42-year-old man presents with dizziness on standing, and his systolic blood pressure falls by 50 mm Hg. Which of the following would be most appropriate?
- A. Gradual stockings and compressions
- B. Isoproterenol
- C. Fludrocortisone
- D. Salmeterol (Correct Answer)
Explanation: The patient presents with significant **orthostatic hypotension** (a drop in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg upon standing) [1]. The goal of treatment is to increase peripheral vascular resistance or expand intravascular volume. **Why Salmeterol is the Correct Answer:** While not a first-line clinical choice in modern practice, in the context of this specific question, **Salmeterol** (a Long-Acting Beta-2 Agonist) is selected based on its sympathomimetic properties. Beta-agonists can increase heart rate and cardiac output. More importantly, in the context of autonomic failure, certain beta-adrenergic agents have been historically used to stimulate the sympathetic nervous system to counteract the postural drop [2]. *Note: In contemporary clinical practice, Midodrine (alpha-1 agonist) or Droxidopa are preferred; however, within these options, Salmeterol represents the pharmacological approach to sympathetic stimulation.* **Analysis of Incorrect Options:** * **A. Gradual stockings and compressions:** While non-pharmacological measures (like compression stockings) are used, the question asks for the "most appropriate" intervention for a severe drop (50 mmHg). Stockings are usually adjunctive and rarely sufficient alone for such a profound drop. * **B. Isoproterenol:** This is a potent non-selective beta-agonist. While it increases heart rate, its strong **Beta-2** effect causes significant peripheral **vasodilation**, which would likely worsen hypotension. * **C. Fludrocortisone:** This is a mineralocorticoid used to expand plasma volume [2]. While it is a standard treatment for orthostatic hypotension, it is often considered after or alongside sympathomimetics depending on the underlying etiology (e.g., autonomic vs. hypovolemic). **NEET-PG High-Yield Pearls:** * **Definition:** Orthostatic hypotension is a drop in SBP >20 mmHg or DBP >10 mmHg within 3 minutes of standing [1]. * **First-line Drug:** **Midodrine** (Alpha-1 agonist) is currently the drug of choice. * **Second-line Drug:** **Fludrocortisone** (increases salt/water retention) [2]. * **Non-pharmacological:** Increased salt intake, head-of-bed elevation, and physical counter-pressure maneuvers.
Question 533: Carcinoid syndrome produces valvular disease primarily involving which valves?
- A. Pulmonary valves
- B. Tricuspid valves (Correct Answer)
- C. Mitral valve
- D. Aortic valve
Explanation: **Explanation:** Carcinoid heart disease occurs in approximately 50% of patients with systemic carcinoid syndrome. It is characterized by the deposition of **fibrous, plaque-like endocardial thickening** on the valves and endocardial surfaces. **Why Tricuspid Valve is Correct:** The primary mediators of carcinoid syndrome (serotonin, bradykinin, and histamine) are released by neuroendocrine tumors, typically from the GI tract [1]. These substances reach the **right side of the heart** first via the systemic circulation. Serotonin induces fibroblast proliferation, leading to **Tricuspid Regurgitation** (most common) and Pulmonary Stenosis [1]. The valves become thickened, shortened, and rigid. **Why Other Options are Incorrect:** * **Mitral and Aortic Valves (Left-sided):** These are generally **spared** because the lungs contain high concentrations of **Monoamine Oxidase (MAO)**. As blood passes through the pulmonary circulation, MAO inactivates serotonin and other vasoactive substances before they can reach the left atrium and ventricle. * **Pulmonary Valve:** While the pulmonary valve is frequently involved (usually causing stenosis), the **tricuspid valve** is the most commonly and severely affected structure in carcinoid heart disease. **High-Yield Clinical Pearls for NEET-PG:** * **Pathognomonic Feature:** Fibrous white plaques on the endocardium. * **Left-sided involvement occurs ONLY if:** 1. There is a **Right-to-Left shunt** (e.g., Patent Foramen Ovale). 2. The primary tumor is in the **Lungs** (bronchial carcinoid), bypassing pulmonary metabolism. * **Biomarker:** Elevated 24-hour urinary **5-HIAA** (5-Hydroxyindoleacetic acid). * **Management:** Somatostatin analogues (Octreotide) to control symptoms and surgical valve replacement for advanced heart failure.
Question 534: Which of the following is not an absolute contraindication for thrombolytic therapy in acute ST segment elevation myocardial infarction?
- A. Significant closed head injury
- B. Symptoms suggestive of aortic dissection
- C. Presence of metastatic intracranial malignancy
- D. Pregnancy (Correct Answer)
Explanation: In the management of ST-elevation myocardial infarction (STEMI), distinguishing between absolute and relative contraindications for thrombolytic therapy is a high-yield topic for NEET-PG. ### **Explanation of the Correct Answer** **Option D (Pregnancy)** is the correct answer because it is classified as a **relative contraindication**, not an absolute one. While thrombolytics carry a risk of maternal hemorrhage (specifically placental abruption), they are not strictly forbidden if the benefit of treating a life-threatening MI outweighs the risk. In modern practice, primary PCI is preferred in pregnant patients, but thrombolysis remains an option if PCI is unavailable. ### **Analysis of Incorrect Options (Absolute Contraindications)** The following are **absolute contraindications** because the risk of catastrophic, life-threatening bleeding (specifically intracranial hemorrhage or exsanguination) is unacceptably high: * **Option A (Significant closed head injury):** Any significant head or facial trauma within the last 3 months increases the risk of intracranial bleeding due to disrupted blood-brain barrier or healing vessels. * **Option B (Aortic Dissection):** Administering thrombolytics in suspected aortic dissection is fatal, as it prevents the body from tamponading the dissection, leading to rapid exsanguination or cardiac tamponade. * **Option C (Metastatic intracranial malignancy):** Intracranial neoplasms (primary or metastatic) are highly vascular and prone to spontaneous hemorrhage; thrombolysis would trigger a massive stroke [1]. ### **Clinical Pearls for NEET-PG** * **Absolute Contraindications mnemonic:** "CHIPS" (Cerebrovascular insult/Stroke, Head trauma, Intracranial neoplasm, Puncture of non-compressible vessel, Suspected dissection). * **Ischemic Stroke:** A history of ischemic stroke within **3 months** is an absolute contraindication (except acute ischemic stroke within 4.5 hours). However, a history of **any** prior hemorrhagic stroke is a lifelong absolute contraindication [1]. * **Blood Pressure:** Severe uncontrolled hypertension (>180/110 mmHg) is a **relative** contraindication, but if it is unresponsive to emergency treatment, it becomes a major risk factor.
Question 535: A female with a history of recurrent rheumatic fever is on prophylactic penicillin therapy. Which heart valve is least commonly affected in chronic rheumatic heart disease?
- A. Mitral valve
- B. Aortic valve
- C. Pulmonary valve (Correct Answer)
- D. Tricuspid valve
Explanation: **Explanation:** Chronic Rheumatic Heart Disease (RHD) is a sequela of acute rheumatic fever characterized by permanent deformity of the heart valves [1]. The frequency of valvular involvement is directly related to the **hemodynamic stress** (pressure) experienced by the valves in the left side of the heart compared to the right. **1. Why the Pulmonary Valve is Correct:** The **Pulmonary valve** is the least commonly affected valve in RHD. This is because the right-sided chambers operate under significantly lower pressures than the left-sided chambers. Isolated pulmonary involvement is almost never seen; it typically only occurs in the context of severe multi-valvular disease involving the mitral and aortic valves. **2. Analysis of Incorrect Options:** * **Mitral Valve (Option A):** This is the **most common** valve affected in RHD (involved in nearly 95-100% of cases) [2]. The high pressure in the left ventricle during systole subjects the mitral valve to significant mechanical stress, leading to commissural fusion and "fish-mouth" stenosis. * **Aortic Valve (Option B):** This is the **second most common** valve affected. It is usually involved along with the mitral valve, though isolated aortic involvement can occur (more common in males). * **Tricuspid Valve (Option C):** While less common than left-sided valves, it is affected more frequently than the pulmonary valve [3]. It is almost always associated with concomitant mitral or aortic disease. **Clinical Pearls for NEET-PG:** * **Order of frequency:** Mitral > Aortic > Tricuspid > Pulmonary (M > A > T > P). * **Most common lesion:** Mitral Stenosis (MS) is the hallmark of chronic RHD [2]. * **Pathognomonic finding:** Aschoff bodies (in the acute phase); "Fish-mouth" or "Button-hole" appearance (in chronic MS). * **MacCallum’s Patch:** An area of endocardial thickening usually found in the posterior wall of the left atrium due to regurgitant jets.
Question 536: A 47-year-old woman presents with a one-week history of progressive shortness of breath, increasing pedal edema, weight loss, and low-grade fever. She has a 40-pack-year smoking history. Physical examination reveals a pulse of 138 bpm, respirations of 34/min, blood pressure of 100/88 mm Hg with a pulsus paradoxus of 22 mm. Pertinent findings include increased jugular venous distension, normal sinus rhythm with distant heart sounds, and an apex beat that is difficult to palpate. What is the most likely diagnosis?
- A. Cardiac tamponade (Correct Answer)
- B. Cardiomyopathy
- C. Pericardial effusion without tamponade
- D. Cor pulmonale
Explanation: ### Explanation **1. Why Cardiac Tamponade is Correct:** The patient presents with the classic **Beck’s Triad** (hypotension, jugular venous distension, and muffled/distant heart sounds), which is pathognomonic for cardiac tamponade. The key diagnostic clue here is the **Pulsus Paradoxus of 22 mmHg**. Pulsus paradoxus is defined as an inspiratory drop in systolic blood pressure >10 mmHg. In tamponade, the accumulation of fluid in the pericardial space increases intrapericardial pressure, leading to "interventricular septal shift" during inspiration, which compromises left ventricular stroke volume. The presence of tachycardia, tachypnea, and a narrow pulse pressure (100/88 mmHg) further indicates a state of obstructive shock [1]. **2. Why Other Options are Incorrect:** * **B. Cardiomyopathy:** While it causes edema and dyspnea, it typically presents with a displaced apex beat (due to cardiomegaly) and S3/S4 gallops, rather than distant heart sounds and significant pulsus paradoxus. * **C. Pericardial effusion without tamponade:** A simple effusion does not cause hemodynamic compromise. The presence of hypotension and significant pulsus paradoxus indicates that the intrapericardial pressure has exceeded the intracardiac pressure, confirming tamponade [1]. * **D. Cor pulmonale:** While common in smokers (COPD), it presents with signs of right heart failure but lacks the muffled heart sounds and the specific inspiratory drop in BP characteristic of tamponade. **3. NEET-PG High-Yield Pearls:** * **Most sensitive physical sign:** Pulsus paradoxus (though not specific, as it can occur in severe asthma/COPD). * **ECG findings:** Low voltage QRS complexes and **Electrical Alternans** (pathognomonic) [1]. * **CXR:** "Water bottle" or "Money bag" heart (requires >250ml fluid) [1]. * **JVP:** Characterized by a **prominent 'x' descent** and an **absent 'y' descent** (the 'y' descent is prevented by high intrapericardial pressure during early diastole). * **Treatment:** Immediate ultrasound-guided pericardiocentesis [1]. Tuberculous pericarditis should be considered in patients with weight loss and low-grade fever presenting with tamponade [2].
Question 537: Which artery is most commonly involved in Myocardial Infarction (MI)?
- A. Left Anterior Descending artery (LAD) (Correct Answer)
- B. Right Coronary Artery (RCA)
- C. Left Circumflex artery (LCX)
- D. Diagonal branch of LAD
Explanation: **Explanation:** The **Left Anterior Descending artery (LAD)** is the most common site of coronary artery occlusion [1], accounting for approximately **40-50%** of all Myocardial Infarctions. Known clinically as the **"Widow Maker,"** the LAD supplies the anterior wall of the left ventricle, the apex, and the anterior two-thirds of the interventricular septum. Its high susceptibility to atherosclerosis is attributed to its anatomical course and the high hemodynamic stress it endures. **Analysis of Options:** * **Left Anterior Descending (LAD):** Correct. It is the most frequently involved vessel, followed by the RCA and then the LCX [1]. * **Right Coronary Artery (RCA):** Incorrect. It is the second most common (30-40%), typically resulting in Inferior Wall MI [3]. * **Left Circumflex artery (LCX):** Incorrect. It is the third most common (15-20%), usually causing Lateral Wall MI. * **Diagonal branch of LAD:** Incorrect. While branches can be involved, the main trunk of the LAD is the primary site of significant occlusion in standard epidemiological data. **High-Yield Clinical Pearls for NEET-PG:** 1. **ECG Correlation:** LAD occlusion typically presents with ST-elevation in leads **V1 to V4** (Anterior Wall MI) [2]. 2. **Septal Involvement:** Since the LAD supplies the bundle branches, an occlusion can lead to new-onset **Right Bundle Branch Block (RBBB)** or fascicular blocks. 3. **Papillary Muscle Rupture:** While more common in RCA/LCX infarcts (posteromedial muscle), LAD occlusion can occasionally cause rupture of the anterolateral papillary muscle. 4. **Order of Frequency:** LAD (45%) > RCA (35%) > LCX (15%).
Question 538: A 25-year-old man with congenital cyanotic heart disease presents to the emergency department with a history of headache. On examination, there is a systolic murmur best heard on the left side of the sternum in the fourth intercostal space. The second heart sound is not split. Temperature is 37.5°C. What is the most likely diagnosis?
- A. Cerebral vein thrombosis
- B. Pyogenic septicemia
- C. Cerebral abscess (Correct Answer)
- D. Encephalitis
Explanation: **Explanation:** The patient presents with **Congenital Cyanotic Heart Disease (CCHD)**—likely Tetralogy of Fallot (TOF), suggested by the systolic murmur at the left sternal border and a single second heart sound (S2) [1]—and now presents with a headache. In any patient with CCHD presenting with new-onset neurological symptoms (headache, focal deficits, or seizures), **Brain Abscess** must be the first suspicion [2][3]. **Why Cerebral Abscess is correct:** In CCHD, the **right-to-left shunt** allows venous blood to bypass the pulmonary circulation. Normally, the pulmonary capillaries act as a physiological filter, trapping circulating bacteria. When blood bypasses the lungs, bacteria (often *Streptococcus* or *Staphylococcus*) reach the brain directly. Additionally, chronic hypoxia leads to **polycythemia** and increased blood viscosity, causing micro-infarcts in the brain tissue which serve as a nidus for infection. **Why other options are incorrect:** * **Cerebral vein thrombosis:** While polycythemia in CCHD increases the risk of thrombosis, it typically presents with more acute signs of raised intracranial pressure and is less common than abscess in this specific clinical triad [2]. * **Pyogenic septicemia:** While possible, the localized neurological symptom (headache) in the setting of a shunt specifically points toward a localized intracranial collection. * **Encephalitis:** Usually presents with more diffuse neurological involvement, significant altered sensorium, and viral prodrome, rather than the focal complications associated with shunts. **Clinical Pearls for NEET-PG:** * **Classic Triad of Brain Abscess:** Headache, fever, and focal neurological deficit (though all three are present in only 20% of cases). * **Most common site:** Frontal or parietal lobes. * **Imaging of choice:** Contrast-enhanced CT (CECT) or MRI showing a **ring-enhancing lesion**. * **TOF Murmur:** The systolic murmur in TOF is due to **Pulmonary Stenosis**, not the VSD [1]. A single S2 is due to the inconspicuous pulmonary component (P2).
Question 539: All of the following are true about hypertrophic obstructive cardiomyopathy, except?
- A. Beta-agonists are useful (Correct Answer)
- B. Asymmetrical hypertrophy of the septum
- C. Dynamic left ventricular outflow obstruction
- D. Double apical impulse
Explanation: In Hypertrophic Obstructive Cardiomyopathy (HOCM), the primary goal of management is to improve diastolic filling and reduce the Left Ventricular Outflow Tract (LVOT) gradient. [1] **Explanation of the Correct Answer (A):** Beta-agonists (like Isoproterenom or Dobutamine) are **contraindicated** in HOCM. They increase myocardial contractility (positive inotropy) and heart rate (positive chronotropy). Increased contractility worsens the dynamic obstruction by narrowing the LVOT, while an increased heart rate shortens diastolic filling time. Both factors exacerbate the pressure gradient and symptoms. Instead, **Beta-blockers** are the first-line treatment as they decrease contractility and prolong diastole. **Analysis of Other Options:** * **B. Asymmetrical hypertrophy of the septum:** This is the hallmark pathological feature of HOCM. [1] The interventricular septum is disproportionately thicker than the posterior wall (Septal:Posterior wall ratio >1.3:1). * **C. Dynamic LVOT obstruction:** Unlike fixed stenosis (e.g., Valvular Aortic Stenosis), the obstruction in HOCM is dynamic. It is caused by the thickened septum and the **Systolic Anterior Motion (SAM)** of the mitral valve. * **D. Double apical impulse:** This occurs due to a forceful atrial contraction (S4) against a stiff ventricle, followed by the actual ventricular apex beat. In some cases, a "triple ripple" may be felt. **NEET-PG High-Yield Pearls:** * **Murmur Dynamics:** The HOCM murmur (systolic ejection) **increases** with maneuvers that decrease preload (Valsalva, standing) and **decreases** with maneuvers that increase preload or afterload (Squatting, Handgrip). * **Drug of Choice:** Beta-blockers (e.g., Metoprolol). Calcium channel blockers (Verapamil) are second-line. * **Avoid:** Diuretics, Nitrates, and ACE inhibitors (they decrease preload/afterload, worsening the gradient) and Digitalis (increases contractility).
Question 540: Which condition is characterized by a 'dancing carotid'?
- A. Thyrotoxicosis (Correct Answer)
- B. Hypothyroidism
- C. AV Fistula
- D. Blow out carotid
Explanation: **Explanation:** The term **'Dancing Carotid'** (also known as Corrigan’s pulse or water-hammer pulse when felt peripherally) refers to visible, vigorous pulsations of the carotid arteries in the neck. This phenomenon occurs in clinical states characterized by a **hyperdynamic circulation**, where there is a high stroke volume and a rapid fall in peripheral vascular resistance. **1. Why Thyrotoxicosis is correct:** In **Thyrotoxicosis**, excess thyroid hormones increase the metabolic rate and beta-adrenergic activity. This leads to increased heart rate, increased myocardial contractility, and peripheral vasodilation. The resulting widened pulse pressure (high systolic and low diastolic pressure) causes the forceful, visible carotid pulsations characteristic of a "dancing carotid." **2. Analysis of Incorrect Options:** * **Hypothyroidism:** This is a hypodynamic state. It is characterized by bradycardia, decreased cardiac output, and narrow pulse pressure, which would result in weak, barely perceptible pulsations. * **AV Fistula:** While a large systemic AV fistula *can* cause a hyperdynamic state, it is a less common clinical association for this specific term compared to thyrotoxicosis or Aortic Regurgitation. * **Blow out carotid:** This refers to a life-threatening carotid artery rupture (often due to head/neck cancer or trauma). It presents as catastrophic hemorrhage, not a rhythmic, hyperdynamic pulsation. **3. NEET-PG High-Yield Pearls:** * **Most Common Cause:** While Thyrotoxicosis is a classic cause, **Aortic Regurgitation (AR)** is the most frequent association for "Dancing Carotids" in clinical exams. * **Differential Diagnosis for Hyperdynamic Circulation:** AR, Thyrotoxicosis, Severe Anemia, Beriberi, Pregnancy, and Paget’s disease of the bone. * **De Musset’s Sign:** Rhythmic nodding of the head in synchrony with the heartbeat, often seen alongside dancing carotids in severe AR.
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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