Cardiology Practice Questions

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: All of the following are associated with Atrioventricular block, except?

Cushing's syndrome. **Explanation:** Atrioventricular (AV) block refers to a delay or interruption in the transmission of electrical impulses from the atria to the ventricles [1]. This can be caused by structural damage, autonomic imbalance, or metabolic disturbances. **Why Cushing’s Syndrome is the correct answer:** Cushing’s syndrome is characterized by an excess of glucocorticoids. While it leads to cardiovascular complications like hypertension and metabolic syndrome, it is **not** typically associated with AV conduction delays. In fact, the electrolyte abnormality often seen in Cushing’s is **hypokalemia**, which more commonly predisposes patients to tachyarrhythmias and increased myocardial excitability rather than heart block [2]. **Analysis of Incorrect Options:** * **Hyperkalemia:** Elevated potassium levels decrease the resting membrane potential, leading to slowed conduction through the AV node and His-Purkinje system [2]. It is a classic cause of progressive heart block and sine-wave patterns. * **Hypomagnesemia:** Magnesium is a cofactor for the Na+/K+-ATPase pump. Deficiency can lead to various arrhythmias, including AV blocks and Torsades de Pointes, often by exacerbating other electrolyte imbalances. * **Hypothyroidism:** Myxedema is a well-known cause of reversible AV block. It causes interstitial edema of the conduction system and increased vagal tone, leading to bradycardia and prolonged PR intervals. **High-Yield Clinical Pearls for NEET-PG:** * **Reversible causes of AV block:** Think of the mnemonic **"DIE"**: **D**rugs (Beta-blockers, CCBs, Digoxin), **I**schemia (Inferior wall MI), and **E**lectrolytes (Hyperkalemia) [2]. * **Infectious causes:** Lyme disease and Chagas disease are high-yield associations for heart block. * **Inferior Wall MI:** Frequently involves the RCA, which supplies the AV node in 90% of individuals, leading to transient AV blocks [3].

Q: Which of the following are causes of restrictive cardiomyopathy?

Amyloidosis, Sarcoidosis, Viral Myopathy. **Explanation:** Restrictive Cardiomyopathy (RCM) is characterized by rigid ventricular walls that resist diastolic filling, leading to elevated filling pressures despite normal or near-normal systolic function. **1. Why Option A is Correct:** The correct answer includes conditions that cause myocardial infiltration or inflammation leading to fibrosis: * **Amyloidosis:** The most common cause of RCM [2]. Deposition of amyloid proteins in the interstitium causes the myocardium to become stiff and non-compliant [2]. * **Sarcoidosis:** Granulomatous infiltration leads to scarring and restrictive physiology (though it can also present with conduction blocks). * **Viral Myopathy:** While viral infections typically cause Dilated Cardiomyopathy (DCM) [1], the **post-inflammatory fibrotic stage** of viral myocarditis can result in a restrictive pattern. **2. Why Other Options are Incorrect:** * **Alcohol-induced Myopathy:** This is a classic cause of **Dilated Cardiomyopathy (DCM)** [1]. Chronic alcohol consumption exerts a direct toxic effect on myocytes, leading to ventricular enlargement and impaired systolic function (reduced ejection fraction), rather than restriction [2]. * **Storage Diseases:** While some storage diseases (like Hemochromatosis or Fabry disease) can cause RCM [2], the presence of "Alcohol-induced myopathy" in options B, C, and D automatically disqualifies them. **NEET-PG High-Yield Pearls:** * **Amyloidosis:** Look for "Sparkling/Speckled" appearance on Echocardiography and low voltage ECG despite thick walls. * **Endomyocardial Fibrosis (EMF):** A common cause of RCM in tropical regions (like South India), often associated with eosinophilia (Löffler’s endocarditis) [2]. * **Differentiating RCM from Constrictive Pericarditis:** This is a favorite exam topic. RCM usually shows a higher BNP and lacks the "respiratory variation" in ventricular filling seen in pericarditis.

Q: What does a tall R wave in the ECG represent?

Right ventricular hypertrophy. ### Explanation **Correct Answer: C. Right ventricular hypertrophy (RVH)** **Underlying Concept:** In a normal ECG, the left ventricle (LV) is much larger than the right ventricle (RV), so the electrical forces are directed toward the left. This results in a small R wave and a deep S wave in lead V1 [1]. In **Right Ventricular Hypertrophy (RVH)**, the increased muscle mass of the RV shifts the electrical vector toward the right and anteriorly. This reversal of the normal R-wave progression leads to a **tall R wave in lead V1** (R/S ratio > 1). **Analysis of Incorrect Options:** * **A & B (Atrial Overload):** Atrial abnormalities are primarily reflected in the **P wave**, not the QRS complex [1]. Right atrial overload (P-pulmonale) presents with tall, peaked P waves (>2.5 mm), while left atrial overload (P-mitrale) presents with broad, notched P waves in lead II or a deep terminal negative deflection in V1. * **D (All of the above):** Since atrial overload does not affect R-wave height, this option is incorrect. **High-Yield Clinical Pearls for NEET-PG:** * **Criteria for RVH:** R wave in V1 > 7 mm, or R/S ratio in V1 > 1, or R in V1 + S in V5/V6 > 10.5 mm. * **Right Axis Deviation:** RVH is almost always accompanied by a rightward shift in the QRS axis (> +90°) [2]. * **Differential Diagnosis for Tall R in V1:** Apart from RVH, consider **Right Bundle Branch Block (RBBB)**, **Posterior Wall MI** (where V1 shows a tall R instead of a Q wave), and **Wolff-Parkinson-White (WPW) Type A**. * **Strain Pattern:** Look for ST-depression and T-wave inversion in V1-V3, indicating RV pressure overload.

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: 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: What is the most important investigation for pericardial effusion?

Echocardiography. **Explanation:** **Echocardiography (Option C)** is the gold standard and most important investigation for pericardial effusion [2]. It is highly sensitive, non-invasive, and can detect as little as 15–20 mL of fluid. Beyond mere detection, it allows for the assessment of the hemodynamic significance of the effusion (e.g., identifying signs of cardiac tamponade like right ventricular diastolic collapse) and helps in quantifying the fluid (small, moderate, or large). **Why other options are incorrect:** * **Cardiac Catheterization (Option A):** While it can show the "square root sign" in constrictive pericarditis or pressure equalization in tamponade, it is invasive and not used for primary diagnosis [1]. * **Ultrasound (Option B):** While echocardiography is technically a specialized form of ultrasound, in clinical exams, "Echocardiography" is the specific and preferred terminology for cardiac imaging. * **X-ray Chest (Option D):** An X-ray only shows an enlarged "water-bottle" or "money-bag" heart silhouette once the effusion exceeds 250 mL [2]. It cannot differentiate between cardiomegaly and effusion. **High-Yield Clinical Pearls for NEET-PG:** * **ECG Findings:** Look for low voltage QRS complexes and **electrical alternans** (pathognomonic for large effusions/tamponade) [2]. * **Beck’s Triad (Tamponade):** Hypotension, JVD, and muffled heart sounds. * **Pulsus Paradoxus:** A drop in systolic BP >10 mmHg during inspiration; a key clinical sign of tamponade. * **Treatment:** Pericardiocentesis is the treatment of choice for symptomatic tamponade, often performed under **echo guidance** for safety [2].

Q: Which of the following conditions is a cause of pulsus bisferiens?

Hypertrophic cardiomyopathy. ### Explanation **Pulsus Bisferiens** (or biphasic pulse) is characterized by two strong systolic peaks separated by a mid-systolic dip, felt best in the carotid artery. **Why Hypertrophic Cardiomyopathy (HCM) is correct:** In **Hypertrophic Obstructive Cardiomyopathy (HOCM)**, the first peak represents the rapid initial ejection of blood [4]. This is followed by a sudden mid-systolic obstruction (due to Systolic Anterior Motion of the mitral valve), causing a brief dip in pressure. The second peak occurs as the ventricular pressure rises further to overcome the obstruction and complete the ejection. *Note: Pulsus bisferiens is also classically seen in **Aortic Regurgitation (AR)** or combined **AS + AR**.* **Why the other options are incorrect:** * **A. Left Ventricular Failure:** Characteristically causes **Pulsus Alternans**, where there is a regular rhythm but alternating strong and weak beats due to fluctuating stroke volume [2]. * **B. Cardiac Tamponade:** Classically associated with **Pulsus Paradoxus**, defined as an exaggerated inspiratory drop in systolic blood pressure (>10 mmHg) [3]. * **D. Constrictive Pericarditis:** Also associated with **Pulsus Paradoxus** (in about 1/3 of cases) and Kussmaul’s sign, but not a bisferiens pulse. **High-Yield Clinical Pearls for NEET-PG:** * **Pulsus Bisferiens:** HOCM, AR, and Large PDA. * **Pulsus Parvus et Tardus:** (Slow-rising, low-amplitude pulse) Pathognomonic for **Aortic Stenosis** [4]. * **Dicrotic Pulse:** (Two peaks, one in systole and one in diastole) Seen in low cardiac output states like severe heart failure or sepsis. * **Water-hammer/Corrigan Pulse:** Seen in severe Aortic Regurgitation [1].

Question 1

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 2

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 3

All of the following are associated with Atrioventricular block, except?

Accepted Answer

Cushing's syndrome

Answer

Hyperkalemia

Answer

Hypomagnesemia

Answer

Hypothyroidism

Question 4

Which of the following are causes of restrictive cardiomyopathy?

Accepted Answer

Amyloidosis, Sarcoidosis, Viral Myopathy

Answer

Sarcoidosis, Viral Myopathy, Alcohol-induced myopathy

Answer

Viral Myopathy, Alcohol-induced myopathy, Storage diseases

Answer

Amyloidosis, Viral Myopathy, Alcohol-induced myopathy

Question 5

What does a tall R wave in the ECG represent?

Accepted Answer

Right ventricular hypertrophy

Answer

Right atrial overload

Answer

Left atrial overload

Answer

All of the above

Question 6

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 7

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 8

What is the most important investigation for pericardial effusion?

Accepted Answer

Echocardiography

Answer

Cardiac catheterization

Answer

Ultrasound (USG)

Answer

X-ray chest

Question 9

Which of the following conditions is a cause of pulsus bisferiens?

Accepted Answer

Hypertrophic cardiomyopathy

Answer

Left ventricular failure

Answer

Cardiac tamponade

Answer

Constrictive pericarditis

Question 10

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

Cardiology — MCQs

Cardiology — MCQs

On this page

Practice by Chapter

Want unlimited practice?