Cardiology Practice Questions

Q: Rheumatic fever is commonly associated with affection of which valve?

Mitral valve. Rheumatic Heart Disease (RHD) is a sequela of Acute Rheumatic Fever (ARF) caused by an autoimmune response following a Group A Streptococcal pharyngeal infection. The correct answer is the **Mitral Valve**, as it is the most frequently involved valve in both acute and chronic rheumatic carditis [1]. **1. Why Mitral Valve is Correct:** The mitral valve is affected in nearly **95-100%** of cases of RHD. The high hemodynamic stress and pressure gradients on the left side of the heart are believed to make the mitral and aortic valves more susceptible to the inflammatory process and subsequent scarring (commissural fusion). In the acute phase, it typically presents as mitral regurgitation [1]; in the chronic phase, it is the leading cause of mitral stenosis. **2. Analysis of Incorrect Options:** * **Aortic Valve (Option C):** This is the second most common valve involved (approx. 20-30%). It is rarely affected in isolation and is usually seen in combination with mitral valve disease. * **Tricuspid Valve (Option A):** Involvement is uncommon (approx. 5%) and almost always occurs secondary to significant mitral and aortic disease [1]. * **Pulmonary Valve (Option D):** This is the least commonly affected valve in RHD. Isolated rheumatic pulmonary valve disease is extremely rare. **High-Yield Clinical Pearls for NEET-PG:** * **Order of frequency of valve involvement:** Mitral > Aortic > Tricuspid > Pulmonary (M > A > T > P). * **Most common lesion in RHD:** Mitral Regurgitation (Acute/Early); Mitral Stenosis (Chronic) [1]. * **Pathognomonic Histology:** **Aschoff bodies** (found in the myocardium) and **Anitschkow cells** (caterpillar cells). * **McCallum’s Patch:** An area of endocardial thickening in the posterior wall of the left atrium, usually due to the jet effect of mitral regurgitation.

Q: What is the secondary prophylaxis for a patient with a history of myocardial infarction who was previously treated with antiplatelet and thrombolytic therapy?

Beta-blockers. The primary goal of secondary prophylaxis post-Myocardial Infarction (MI) is to reduce mortality, prevent recurrent ischemic events, and limit ventricular remodeling. **Why Beta-blockers are the correct choice:** Beta-blockers (e.g., Metoprolol, Carvedilol, Bisoprolol) are a cornerstone of post-MI therapy [1]. They decrease myocardial oxygen demand by reducing heart rate, blood pressure, and contractility. More importantly, they provide **mortality benefits** by preventing life-threatening ventricular arrhythmias and reducing the risk of sudden cardiac death [4]. Clinical trials have consistently shown that long-term beta-blocker therapy reduces both all-cause mortality and re-infarction rates. **Why other options are incorrect:** * **Calcium Channel Blockers (CCBs):** These are not first-line for secondary prophylaxis. While they can be used for symptom control in patients who cannot tolerate beta-blockers, they do not provide the same proven mortality benefit [1]. Short-acting nifedipine is actually contraindicated as it may cause reflex tachycardia [1]. * **Nitrates:** These are excellent for symptomatic relief of angina (vasodilation), but they have **no mortality benefit** in the chronic post-MI setting [3]. * **Aldosterone Antagonists:** While used post-MI, they are specifically indicated only for patients with a reduced Ejection Fraction (EF ≤ 40%) and either heart failure symptoms or diabetes. They are not the universal first-line choice compared to beta-blockers [2]. **High-Yield Clinical Pearls for NEET-PG:** * **The "Big Four" for Post-MI Prophylaxis:** Aspirin (Antiplatelets), Beta-blockers, ACE inhibitors/ARBs, and Statins [3]. * **Contraindications:** Avoid beta-blockers in acute heart failure (until stabilized), severe bradycardia, or high-grade AV blocks [1]. * **Cardioselective agents:** Metoprolol and Bisoprolol are preferred to minimize bronchospasm in patients with mild COPD.

Q: Severity of Aortic stenosis is determined by?

All the above. The severity of Aortic Stenosis (AS) is assessed through a combination of clinical symptoms, physical examination findings, and electrocardiographic/echocardiographic data. [1] **Explanation of the Correct Answer:** The correct answer is **D (All the above)** because each option represents a marker of advanced valvular obstruction and the resulting pressure overload on the left ventricle (LV). * **Late Ejection Systolic Murmur:** In mild AS, the murmur peaks early. As the orifice narrows, it takes longer for the LV to eject blood across the stenotic valve, causing the murmur to peak later in systole. [1], [3] A **late-peaking murmur** is a classic bedside sign of severe AS. [1] * **ST-T Changes:** Chronic pressure overload leads to significant LV strain. On an ECG, this manifests as ST-segment depression and T-wave inversion (LV strain pattern) in the lateral leads (V5, V6, I, aVL). The presence of these changes correlates with increased LV mass and disease severity. * **LVH with Displaced Apex:** To overcome the high afterload, the LV undergoes concentric hypertrophy. Eventually, this leads to ventricular remodeling and dilatation. A **sustained, heaving, and laterally displaced apex beat** indicates significant LV hypertrophy and potential heart failure, marking advanced disease. [2] **High-Yield Clinical Pearls for NEET-PG:** 1. **Pulsus Parvus et Tardus:** A small-volume and slow-rising carotid pulse is the most reliable physical sign of severe AS. [1] 2. **S2 Heart Sound:** In severe AS, the aortic component (A2) is delayed or absent, leading to a **reversed (paradoxical) splitting of S2** or a single S2. [1], [3] 3. **Gallavardin Phenomenon:** The dissociation between the noisy systolic murmur at the base and musical high-frequency components at the apex (mimicking mitral regurgitation). [1] 4. **Symptom Triad (SAD):** Syncope, Angina, and Dyspnea indicate a poor prognosis and the need for urgent valve replacement.

Q: All of the following are true regarding hypertrophic obstructive cardiomyopathy, EXCEPT:

Digitalis is useful. **Explanation:** Hypertrophic Obstructive Cardiomyopathy (HOCM) is characterized by a dynamic pressure gradient in the subaortic area, primarily due to asymmetrical septal hypertrophy and systolic anterior motion (SAM) of the mitral valve. **Why Option A is the Correct Answer (The Exception):** **Digitalis (Digoxin)** is generally **contraindicated** in HOCM. As a positive inotrope, Digitalis increases myocardial contractility. In HOCM, increased contractility worsens the left ventricular outflow tract (LVOT) obstruction by narrowing the outflow path further during systole. Similarly, diuretics and vasodilators (which reduce preload/afterload) should be avoided as they exacerbate the gradient. **Analysis of Incorrect Options:** * **Option B (LVOT obstruction):** This is the hallmark of HOCM. The hypertrophy of the interventricular septum creates a physical barrier, leading to a dynamic pressure gradient. * **Option C (Asymmetrical septal thickness):** The classic morphological pattern in HOCM is disproportionate septal hypertrophy (ASH), where the septum is significantly thicker than the posterior wall (Septum:PW ratio > 1.3:1). * **Option D (Double apical impulse):** A "double" or "triple" apical impulse is a classic physical sign. The first component is a forceful atrial contraction (S4) against a stiff ventricle, followed by the actual ventricular apex beat. **NEET-PG High-Yield Pearls:** 1. **Drug of Choice:** Beta-blockers (first-line) or Verapamil (non-dihydropyridine CCBs) to improve diastolic filling. 2. **Murmur Dynamics:** The systolic murmur of HOCM **increases** with Valsalva and standing (decreased preload) and **decreases** with squatting or handgrip (increased preload/afterload). 3. **Genetic Basis:** Most commonly due to mutations in genes encoding sarcomeric proteins (e.g., Beta-myosin heavy chain, Myosin-binding protein C) [1].

Q: Which of the following is the investigation of choice for reversible myocardial ischemia?

Thallium scan. ### Explanation The investigation of choice for **reversible myocardial ischemia** is a **Thallium scan** (Myocardial Perfusion Imaging). [1] **1. Why Thallium Scan is Correct:** Thallium-201 is a potassium analogue that enters viable myocardial cells via the Na+/K+ ATPase pump. In a stress-redistribution protocol, areas of ischemia appear as "cold spots" during exercise (due to decreased blood flow) but "fill in" during rest (redistribution) [1]. This ability to demonstrate **reversible perfusion defects** distinguishes viable but ischemic myocardium from infarcted (scarred) tissue, which remains a "cold spot" even at rest. [1] **2. Why Other Options are Incorrect:** * **MUGA Scan:** This is the gold standard for accurately measuring the **Left Ventricular Ejection Fraction (LVEF)**. It does not assess perfusion or ischemia. * **Resting Echocardiogram:** While it can show regional wall motion abnormalities (RWMA), a resting echo cannot differentiate between an old infarct and active ischemia. It is often normal in patients with stable angina at rest. * **Coronary Angiography (CAG):** This is the gold standard for visualizing **coronary anatomy** and the degree of luminal stenosis [2]. However, it is an anatomical study, not a functional one; it cannot definitively prove if a specific stenosis is causing reversible ischemia at the cellular level. [2] **Clinical Pearls for NEET-PG:** * **Gold Standard for Viability:** PET scan (using FDG) is the most sensitive, but Thallium-201 is the standard clinical choice for "reversible ischemia." * **Hibernating Myocardium:** Chronic but reversible ischemia where wall motion is impaired; it improves after revascularization. * **Stunned Myocardium:** Temporary dysfunction persisting after reperfusion (e.g., post-PCI), despite restored blood flow.

Question 1

Which of the following is an absolute contraindication for exercise testing?

Accepted Answer

Aortic stenosis

Answer

Unstable angina

Answer

Peripheral vascular disease

Answer

One week following myocardial infarction

Question 2

Rheumatic fever is commonly associated with affection of which valve?

Accepted Answer

Mitral valve

Answer

Tricuspid valve

Answer

Aortic valve

Answer

Pulmonary valve

Question 3

All of the following are major criteria in the diagnosis of Acute Rheumatic Fever, except?

Accepted Answer

Migratory Polyarthralgia

Answer

Subcutaneous Nodules

Answer

Chorea

Answer

Carditis

Question 4

All of the following are true regarding hypertrophic cardiomyopathy EXCEPT:

Accepted Answer

Digoxin is helpful

Answer

Irregular thickness of septa

Answer

Dynamic obstruction

Answer

Double apical impulse

Question 5

What is the secondary prophylaxis for a patient with a history of myocardial infarction who was previously treated with antiplatelet and thrombolytic therapy?

Accepted Answer

Beta-blockers

Answer

Calcium channel blockers

Answer

Nitrates

Answer

Aldosterone antagonists

Question 6

Severity of Aortic stenosis is determined by?

Accepted Answer

All the above

Answer

Late ejection systolic murmur

Answer

ST-T changes

Answer

Left ventricular hypertrophy with displaced apex

Question 7

Infective endocarditis is least likely to occur in which of the following conditions?

Accepted Answer

Atrial Septal Defect (ASD)

Answer

Ventricular Septal Defect (VSD)

Answer

Tetralogy of Fallot

Answer

Coarctation of the Aorta

Question 8

In hypertension, on what factor does end-organ involvement primarily depend?

Accepted Answer

Diastolic blood pressure

Answer

Systolic blood pressure

Answer

Mean capillary blood pressure

Answer

Decreased elasticity of blood vessels

Question 9

All of the following are true regarding hypertrophic obstructive cardiomyopathy, EXCEPT:

Accepted Answer

Digitalis is useful

Answer

Left ventricular outflow obstruction

Answer

Asymmetrical septal thickness

Answer

Double apical impulse

Question 10

Which of the following is the investigation of choice for reversible myocardial ischemia?

Accepted Answer

Thallium scan

Answer

MUGA scan

Answer

Resting echocardiogram

Answer

Coronary angiography

Cardiology — MCQs

Cardiology — MCQs

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