Cardiology Practice Questions

Q: Which of the following conditions is characterized by an early diastolic murmur?

Aortic Regurgitation (AR). **Explanation** **Correct Answer: C. Aortic Regurgitation (AR)** The hallmark of Aortic Regurgitation is a high-pitched, blowing **Early Diastolic Murmur (EDM)** [1]. This occurs because, immediately after the closure of the semilunar valves (S2), the pressure in the aorta significantly exceeds the pressure in the left ventricle [2]. This pressure gradient causes blood to regurgitate back into the ventricle at the very beginning of diastole. It is best heard at the left sternal border (Erb’s point) with the patient sitting forward and in deep expiration [2]. **Analysis of Incorrect Options:** * **A. Ventricular Septal Defect (VSD):** Characterized by a loud, harsh **Pansystolic (Holosystolic) murmur**, loudest at the left lower sternal border. * **B. Atrial Septal Defect (ASD):** Does not produce a murmur across the defect itself. Instead, it causes a **Mid-systolic flow murmur** over the pulmonary area due to increased stroke volume across the pulmonary valve, along with a characteristic **fixed split S2** [1]. * **D. Pulmonic Regurgitation (PR):** While PR can cause an EDM (Graham Steell murmur), it is typically associated with pulmonary hypertension. In the context of standard NEET-PG questions, AR is the classic and most common cause of an EDM [2]. Note: Severe PR without pulmonary hypertension usually produces a *mid-diastolic* murmur. **NEET-PG High-Yield Pearls:** * **Austin Flint Murmur:** A mid-diastolic rumble heard in severe AR due to the regurgitant jet displacing the mitral valve leaflet [2]. * **Peripheral Signs of AR:** Look for "Water-hammer pulse" (Corrigan’s pulse), Quincke’s sign (capillary pulsations), and de Musset’s sign (head nodding). * **Dynamic Maneuvers:** Left-sided murmurs (AR, MR, AS) increase in intensity with **expiration**, while right-sided murmurs increase with **inspiration** (Carvallo's sign).

Q: In Myocardial infarction, what is the most specific marker?

Troponin T. The diagnosis of Myocardial Infarction (MI) relies on the detection of a rise and/or fall of cardiac biomarkers, with **Cardiac Troponins (I and T)** being the preferred markers due to their high **myocardial specificity** and sensitivity [1]. **Why Troponin T is the Correct Answer:** Troponins are structural proteins of the cardiac myofibrils. Unlike other enzymes, Troponin I and T have isoforms that are unique to cardiac myocytes. They are released into the bloodstream following even minute areas of myocardial necrosis [1]. Troponin T begins to rise within 3–6 hours of injury and can remain elevated for up to 10–14 days, providing a wide diagnostic window. **Analysis of Incorrect Options:** * **Pro-BNP:** This is a marker of ventricular wall stretch and is primarily used for the diagnosis and prognosis of **Heart Failure**, not for identifying acute necrosis. * **Myoglobin:** This is the **earliest marker** to rise (within 1–2 hours). However, it lacks specificity because it is also found in skeletal muscle and can be elevated due to trauma or strenuous exercise. * **CPK-MB:** While specific to the heart, it is less specific than Troponins [1]. Its primary utility is in detecting **re-infarction** because it returns to baseline quickly (within 48–72 hours), whereas Troponins stay elevated longer. **NEET-PG High-Yield Pearls:** * **Most Specific Marker:** Troponin I (slightly more specific than T in patients with renal failure). * **Earliest Marker:** Myoglobin. * **Marker for Re-infarction:** CPK-MB. * **Gold Standard for Diagnosis:** Cardiac Troponins [1]. * **Bedside Test:** Troponin T (Rapid immunochromatographic test).

Q: Which of the following is untrue regarding sick sinus syndrome?

Coronary artery disease is a common cause.. Sick Sinus Syndrome (SSS) refers to a spectrum of cardiac arrhythmias caused by generalized dysfunction of the sinoatrial (SA) node. **Why Option B is the correct (untrue) statement:** While it is a common misconception, **Coronary Artery Disease (CAD) is NOT a common cause of SSS.** The most frequent underlying cause is **idiopathic degenerative fibrosis** of the SA node and the surrounding atrial myocardium [2]. Although an acute myocardial infarction (especially inferior wall MI) can cause transient SA node dysfunction, chronic CAD rarely leads to the persistent clinical syndrome of SSS. **Analysis of other options:** * **Option A:** SSS occurs most commonly in the **elderly** (typically 7th–8th decade) due to age-related fibro-degenerative changes [2]. * **Option C:** ECG manifestations are notoriously **intermittent** [1]. Patients may alternate between sinus bradycardia, sinus arrest, SA exit block, and paroxysmal supraventricular tachycardias (Tachy-Brady Syndrome) [2]. This often necessitates prolonged monitoring (Holter or ILR) for diagnosis [1]. * **Option D:** The definitive treatment for **symptomatic** SSS is the implantation of a **permanent pacemaker** (usually dual-chamber/DDDR) [1][2]. As the condition is progressive and often exacerbated by necessary rate-controlling drugs, pacing is required to alleviate symptoms like syncope or presyncope. **High-Yield Clinical Pearls for NEET-PG:** * **Tachy-Brady Syndrome:** The most common clinical presentation where periods of bradycardia are followed by paroxysmal atrial tachyarrhythmias (usually Atrial Fibrillation) [2]. * **Pharmacology:** Drugs like Beta-blockers, CCBs, and Digoxin can worsen SSS symptoms and are often the "trigger" for diagnosis. * **Intrinsic Heart Rate:** A key diagnostic feature is the failure of the heart rate to increase appropriately during exercise (Chronotropic Incompetence).

Q: Regarding Hypertrophic Obstructive Cardiomyopathy (HOCM), all are true except?

Autosomal recessive inheritance. Hypertrophic Obstructive Cardiomyopathy (HOCM) is a genetic cardiac disorder characterized by asymmetric septal hypertrophy and left ventricular outflow tract (LVOT) obstruction. **Why Option B is the correct answer (The "Except"):** HOCM is primarily an **Autosomal Dominant** condition with variable penetrance [1]. It is most commonly caused by mutations in genes encoding sarcomeric proteins, specifically the **Beta-myosin heavy chain** (most common) and **Myosin-binding protein C** [1]. It is not autosomal recessive. **Analysis of other options:** * **A. Myocyte disarray:** This is the hallmark histopathological feature of HOCM [1]. The normal parallel alignment of cardiac myocytes is replaced by a chaotic, "disarrayed" pattern, which serves as a substrate for ventricular arrhythmias. * **C. Diastolic failure:** In HOCM, the primary functional abnormality is **diastolic dysfunction**. The hypertrophied, stiff ventricle cannot relax properly during diastole, leading to impaired filling and increased end-diastolic pressure, despite a normal or supranormal Ejection Fraction (EF). * **D. Bifid pulse:** Also known as **Bisferiens pulse** or "spike and dome" pulse. In HOCM, there is a rapid initial contraction (spike), followed by a mid-systolic dip due to LVOT obstruction, and a second slower rise (dome). **NEET-PG High-Yield Pearls:** * **Murmur:** Harsh systolic ejection murmur heard best at the left sternal border. * **Dynamic Auscultation:** The murmur **increases** with Valsalva and standing (decreased preload) and **decreases** with squatting or handgrip (increased preload/afterload). * **ECG:** May show "dagger-like" Q waves in lateral/inferior leads. * **Drug of Choice:** Beta-blockers (first-line) or Verapamil to improve diastolic filling. **Avoid Nitrates and Diuretics** as they worsen the obstruction.

Q: A 60-year-old smoker presents with breathlessness for 2 weeks. On examination, heart rate is 100/min, BP = 90/60 mm Hg, and neck veins are distended with a palpable liver. CXR is shown. What is the probable diagnosis?

Pericardial effusion. ***Pericardial effusion*** - The triad of **hypotension** (90/60 mmHg), **raised JVP** (distended neck veins), and **tachycardia** (100/min) with hepatomegaly suggests **cardiac tamponade** from pericardial effusion. - CXR likely shows the classic **"water-bottle" heart** appearance with enlarged cardiac silhouette, pathognomonic of significant pericardial effusion. *Cor pulmonale* - Results from **chronic lung disease** causing **pulmonary hypertension** and right heart failure, but would typically show signs of underlying lung pathology on CXR. - Usually presents with **elevated JVP** but **normal or elevated blood pressure**, not hypotension as seen here. *Broken heart syndrome* - **Takotsubo cardiomyopathy** typically occurs after severe **emotional or physical stress** in postmenopausal women, not fitting this demographic. - Characterized by **apical ballooning** on echocardiography and **normal coronary arteries**, with different hemodynamic profile than described. *Brugada syndrome* - A **genetic channelopathy** causing **ventricular arrhythmias** and sudden cardiac death, not heart failure symptoms. - Diagnosed by characteristic **ECG pattern** (coved ST-elevation in V1-V3) and **family history**, unrelated to the presented clinical picture.

Q: What is the critical degree of narrowing of coronary vessels that causes angina?

More than 70%. **Explanation:** The concept of "critical stenosis" in cardiology refers to the degree of narrowing at which the coronary artery can no longer increase blood flow to meet the metabolic demands of the myocardium during exertion [1]. **Why 70% is correct:** Under resting conditions, coronary blood flow can remain normal even with significant narrowing due to compensatory distal vasodilation. However, once the luminal diameter is reduced by **more than 70%** (which corresponds to approximately an 80-90% reduction in cross-sectional area), the coronary flow reserve is exhausted. At this threshold, the vessel cannot provide the 3-to-5-fold increase in flow required during exercise, leading to subendocardial ischemia and the clinical symptom of **stable angina** [2]. **Analysis of Incorrect Options:** * **A & B (50% - 60%):** While a 50% reduction is often used to define "obstructive" coronary artery disease (CAD) on angiography, it is usually hemodynamically insignificant at rest and during moderate exercise. Most patients remain asymptomatic at this level. * **D (80%):** While 80% stenosis certainly causes angina, it is not the *minimum* threshold. The "critical" level is established at 70%. Narrowing >90% is typically required to produce symptoms even at rest (unstable angina or decubitus angina). **High-Yield Clinical Pearls for NEET-PG:** * **Stable Angina:** Occurs at >70% stenosis; pain is predictable and relieved by rest/nitroglycerin [1]. * **Rest Angina:** Usually occurs when stenosis exceeds **90%**. * **Left Main Disease:** Considered critical at **>50%** due to the massive amount of myocardium at risk. * **Fractional Flow Reserve (FFR):** A physiological measure used in the cath lab; an FFR **<0.80** indicates a lesion is hemodynamically significant, regardless of the visual percentage.

Q: Giant 'a' waves in JVP occur in all except?

Tricuspid regurgitation. ### Explanation The **'a' wave** in the Jugular Venous Pulse (JVP) represents **atrial contraction** [1]. Giant 'a' waves occur when the right atrium contracts against increased resistance (a non-compliant ventricle or a closed valve). **Why Tricuspid Regurgitation (TR) is the correct answer:** In TR, the 'a' wave is typically normal. Instead, TR is characterized by **giant 'v' waves** (or 'cv' waves). During ventricular systole, blood regurgitates back into the right atrium, causing a prominent systolic surge in pressure. This leads to the "ventricularization" of the JVP and systolic pulsations of the liver. **Analysis of Incorrect Options:** * **Junctional Rhythm:** The atria and ventricles contract simultaneously. Since the tricuspid valve is closed during ventricular systole, the atrium contracts against a closed valve, producing **Cannon 'a' waves** (a form of giant 'a' wave). * **Pulmonary Hypertension:** Increased pressure in the pulmonary circuit leads to right ventricular hypertrophy. The right atrium must contract harder against a stiff, non-compliant right ventricle, resulting in **giant 'a' waves**. * **Complete Heart Block:** There is total AV dissociation. Occasionally, the atrium contracts while the tricuspid valve is closed by ventricular systole, leading to intermittent, irregular **Cannon 'a' waves** [1]. **NEET-PG High-Yield Pearls:** * **Giant 'a' waves:** Seen in Tricuspid Stenosis, Pulmonary Stenosis, and Right Ventricular Hypertrophy (resistance to filling). * **Cannon 'a' waves:** Seen in AV dissociation (Complete heart block, Ventricular Tachycardia) and Junctional rhythms. * **Absent 'a' waves:** Pathognomonic for **Atrial Fibrillation** (no coordinated atrial contraction). * **Prominent 'y' descent:** Seen in Constrictive Pericarditis and TR; **Absent 'y' descent** is seen in Cardiac Tamponade.

Question 1

Which of the following conditions is characterized by an early diastolic murmur?

Accepted Answer

Aortic Regurgitation (AR)

Answer

Ventricular Septal Defect (VSD)

Answer

Atrial Septal Defect (ASD)

Answer

Pulmonic Regurgitation (Severe)

Question 2

Mitral stenosis is associated with which of the following?

Accepted Answer

Right ventricular hypertrophy

Answer

Left ventricular hypertrophy

Answer

Left axis deviation

Answer

QRS complex

Question 3

Low renin hypertension is seen in all of the following conditions, except:

Accepted Answer

Renovascular hypertension

Answer

Essential hypertension

Answer

Conn's syndrome

Answer

Liddle's syndrome

Question 4

Acute aortic regurgitation is seen in all the following conditions except?

Accepted Answer

Acute myocardial infarction

Answer

Marfan's syndrome

Answer

Bacterial endocarditis

Answer

Ankylosing spondylitis

Question 5

In Myocardial infarction, what is the most specific marker?

Accepted Answer

Troponin T

Answer

Pro-Brain Natriuretic Peptide

Answer

Myoglobin

Answer

Creatine Phosphokinase MB (CPK MB)

Question 6

Which of the following is untrue regarding sick sinus syndrome?

Accepted Answer

Coronary artery disease is a common cause.

Answer

Occurs most commonly in the elderly.

Answer

ECG manifestations are often intermittent.

Answer

Most symptomatic patients will require permanent pacing.

Question 7

Regarding Hypertrophic Obstructive Cardiomyopathy (HOCM), all are true except?

Accepted Answer

Autosomal recessive inheritance

Answer

Myocyte disarray

Answer

Diastolic failure

Answer

Bifid pulse

Question 8

A 60-year-old smoker presents with breathlessness for 2 weeks. On examination, heart rate is 100/min, BP = 90/60 mm Hg, and neck veins are distended with a palpable liver. CXR is shown. What is the probable diagnosis?

Accepted Answer

Pericardial effusion

Answer

Cor pulmonale

Answer

Broken heart syndrome

Answer

Brugada syndrome

Question 9

What is the critical degree of narrowing of coronary vessels that causes angina?

Accepted Answer

More than 70%

Answer

More than 50%

Answer

More than 60%

Answer

More than 80%

Question 10

Giant 'a' waves in JVP occur in all except?

Accepted Answer

Tricuspid regurgitation

Answer

Junctional rhythm

Answer

Pulmonary hypertension

Answer

Complete heart block

Cardiology — MCQs

Cardiology — MCQs

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