Cardiology Practice Questions

Q: What is the most appropriate intervention for acute myocardial infarction?

Early primary coronary intervention. **Explanation:** The management of acute ST-elevation myocardial infarction (STEMI) focuses on the rapid restoration of coronary blood flow to salvage myocardium. **Primary Percutaneous Coronary Intervention (PCI)** is the gold standard and most appropriate intervention when performed within 90–120 minutes of first medical contact [1]. **Why Option C is correct:** Primary PCI (angioplasty with or without stenting) is superior to fibrinolysis (thrombolysis) because it achieves higher rates of "TIMI 3 flow" (complete reperfusion), carries a lower risk of intracranial hemorrhage, and significantly reduces the rates of re-infarction and mortality [1]. **Why other options are incorrect:** * **Options A, B, and D:** These involve **Streptokinase**, a first-generation fibrinolytic agent. While fibrinolysis is an alternative if PCI is unavailable within the recommended timeframe, it is pharmacologically inferior to PCI [1]. Furthermore, Streptokinase is non-fibrin-specific and carries a higher risk of systemic bleeding and allergic reactions compared to newer agents like Tenecteplase. While Aspirin and Heparin are essential *adjuncts* in STEMI management, they do not replace the need for definitive mechanical reperfusion (PCI). **High-Yield Clinical Pearls for NEET-PG:** * **Door-to-Balloon Time:** Should be **<90 minutes** (at a PCI-capable hospital) or **<120 minutes** (if transfer is required). * **Door-to-Needle Time:** If PCI is not possible within 120 minutes, fibrinolysis should be initiated within **30 minutes**. * **Absolute Contraindications to Fibrinolysis:** Prior intracranial hemorrhage, known structural cerebrovascular lesion, ischemic stroke within 3 months, or active internal bleeding. * **Drug of Choice:** Tenecteplase is now preferred over Streptokinase due to its fibrin specificity and bolus administration [1].

Q: What is the abnormality shown in the ECG?

Premature ventricular contractions. ***Premature ventricular contractions*** - Characterized by **wide, bizarre QRS complexes** (>120 ms) with **no preceding P wave**, indicating ventricular origin. - Followed by a **compensatory pause** before the next normal beat, distinguishing them from other arrhythmias. *Sine wave pattern* - Associated with **severe hyperkalemia** (K+ >8-9 mEq/L) showing smooth, undulating waves without distinct P, QRS, or T waves. - Represents a **life-threatening electrolyte abnormality** requiring immediate treatment, not isolated premature beats. *ST segment depression* - Indicates **myocardial ischemia** or **subendocardial injury**, appearing as horizontal or downsloping depression ≥1mm. - Would affect multiple leads consistently in **ischemic patterns**, not present as isolated abnormal beats. *Electrical alternans* - Shows **beat-to-beat variation** in QRS amplitude or axis, typically seen in **pericardial effusion** with cardiac tamponade. - Involves **regular rhythm** with alternating QRS morphology, not premature or ectopic beats.

Q: Pulsus bisferiens is seen in all except?

Tetralogy of Fallot. **Explanation:** **Pulsus bisferiens** (or biphasic pulse) is a clinical sign where two systolic peaks are felt in the arterial pulse. The first peak represents the **percussion wave** (rapid ejection) and the second represents the **tidal wave** (reflected wave or continued ejection) [1]. **Why Tetralogy of Fallot (TOF) is the correct answer:** In TOF, the primary hemodynamic issue is right-to-left shunting across a VSD and pulmonary stenosis. This leads to a **reduced stroke volume** being ejected into the systemic circulation. The pulse in TOF is typically small in volume (pulsus parvus) or normal, but it never produces the double-systolic peak characteristic of bisferiens. **Analysis of Incorrect Options:** * **Aortic Regurgitation (AR) + Aortic Stenosis (AS):** This is the classic cause. The AS component creates a slow-rising percussion wave, while the large stroke volume from AR creates a prominent tidal wave. [1] * **Pure Aortic Regurgitation:** Severe AR causes a massive stroke volume ejected rapidly, which can reflect off the peripheral vessels to create a second systolic peak. [1] * **Hypertrophic Obstructive Cardiomyopathy (HOCM):** This produces a "spike and dome" pattern. The initial rapid ejection (spike) is followed by a sudden mid-systolic obstruction, with a subsequent slower ejection (dome). **High-Yield Clinical Pearls for NEET-PG:** 1. **Best site to palpate:** Pulsus bisferiens is best appreciated in the **brachial or femoral arteries** (peripheral arteries), unlike pulsus alternans which is best felt in the carotids. 2. **Differentiating HOCM from AR:** In HOCM, the pulse is "brisk," whereas in AS+AR, the initial rise is often delayed. [1] 3. **Pulsus Parvus et Tardus:** Characteristic of isolated severe Aortic Stenosis (small volume, slow rising). 4. **Water-hammer pulse:** Characteristic of isolated severe AR (rapid upstroke and rapid collapse) [1].

Q: A patient with acute inferior wall myocardial infarction has developed shock. Which of the following is the most likely cause of shock?

Right ventricular infarction. **Explanation:** **Right Ventricular Infarction (RVI)** is the most common cause of shock specifically associated with an **acute inferior wall myocardial infarction (MI)**. In RVI, the right ventricle fails as a pump, leading to decreased preload for the left ventricle, resulting in hypotension and cardiogenic shock [1]. This occurs because the Right Coronary Artery (RCA) typically supplies both the inferior wall of the left ventricle and the right ventricle. **Why the other options are incorrect:** * **Cardiac Rupture (Free Wall):** Usually occurs 3–7 days post-MI and leads to rapid cardiac tamponade and sudden death, rather than isolated shock in the acute phase [2]. * **Interventricular Septal Perforation (VSD):** A mechanical complication occurring 3–5 days post-MI. While it causes shock, it is characterized by a new harsh pansystolic murmur and left-to-right shunt, and is less frequent than RVI in the immediate acute setting. * **Papillary Muscle Rupture:** Typically involves the posteromedial papillary muscle (supplied by the RCA). It causes acute, severe mitral regurgitation and pulmonary edema. While it causes shock, the presence of "clear lungs" in the question stem (implied by typical RVI presentations) points away from this. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Triad of RVI:** Hypotension, Clear Lungs, and Elevated JVP (Kussmaul’s sign may be present). * **Diagnosis:** ST-segment elevation in right-sided leads (especially **V4R**). * **Management:** The mainstay is **aggressive IV fluids** to maintain RV preload. **Avoid nitrates, diuretics, and morphine**, as they reduce preload and can worsen hypotension.

Q: Which of the following is not a major Framingham criterion for heart failure?

Hepatomegaly. To diagnose Heart Failure (HF) using the **Framingham Criteria**, a patient must fulfill **two major criteria** or **one major and two minor criteria**. [1] ### **Why Hepatomegaly is the Correct Answer** **Hepatomegaly** is classified as a **Minor Criterion**. In the Framingham study, minor criteria represent signs and symptoms that are less specific to heart failure and can be caused by other conditions (e.g., liver disease or chronic lung disease). Other minor criteria include bilateral ankle edema, nocturnal cough, dyspnea on exertion, tachycardia (>120 bpm), and pleural effusion. ### **Analysis of Incorrect Options (Major Criteria)** The following are **Major Criteria** because they have a high specificity for the diagnosis of congestive heart failure: * **A. Cardiomegaly:** Detected on chest X-ray; indicates ventricular dilatation. [1] * **B. Paroxysmal Nocturnal Dyspnea (PND):** A highly specific symptom where the patient wakes up gasping for air. [1] * **C. S3 Gallop:** A classic physical sign of ventricular filling into a dilated, non-compliant chamber. [1] ### **High-Yield Clinical Pearls for NEET-PG** * **The "Weight Loss" Rule:** Weight loss of >4.5 kg in 5 days in response to treatment (diuretics) can be considered either a major or minor criterion depending on the clinical context. * **Other Major Criteria to Remember:** * Neck vein distention (JVP) * Acute pulmonary edema * Hepatojugular reflux [1] * Rales (crackles) [1] * **Mnemonic for Major Criteria:** **"SAUCE PAN"** (S3, Acute pulmonary edema, Upper venous congestion/JVP, Cardiomegaly, Effusion—not pleural, but weight loss from diuresis, PND, Ankle edema is minor, Neck vein distention). * **Note:** For NEET-PG, remember that **Hepatomegaly** and **Peripheral Edema** are frequently tested distractors; they are **Minor**, not Major.

Q: A 70-year-old man with a past medical history of ischemic heart disease and hypertension presents to his GP with recurrent episodes of syncope over the past 2 weeks. Based upon this ECG, which of the following clinical findings is most likely to be present?

Canon A waves. ***Canon A waves*** - **Complete heart block (3rd degree AV block)** causes **AV dissociation** where atria and ventricles beat independently, leading to occasional simultaneous atrial and ventricular contractions. - When the **right atrium contracts against a closed tricuspid valve**, it creates prominent **canon A waves** in the jugular venous pulse, which is pathognomonic for complete heart block. *Absent JVP* - The **jugular venous pulse (JVP)** would still be visible in complete heart block, though it may show irregular patterns due to **AV dissociation**. - **Canon A waves** are actually a prominent feature of the JVP in this condition, making absent JVP unlikely. *Absent hepato-jugular reflux* - The **hepato-jugular reflux** test assesses **right heart function** and venous return, which are not directly affected by conduction abnormalities. - Complete heart block primarily affects **electrical conduction**, not the mechanical function of venous return or right heart filling. *Giant V waves* - **Giant V waves** in the JVP indicate severe **tricuspid regurgitation** due to incompetent tricuspid valve during ventricular systole. - Complete heart block causes **conduction abnormalities** rather than valvular incompetence, making giant V waves an unlikely finding.

Q: Atrial fibrillation may occur in all of the following conditions, except?

Hypothyroidism. ### Explanation Atrial Fibrillation (AF) is typically triggered by structural remodeling, atrial stretch, or increased sympathetic activity [1]. **Why Hypothyroidism is the correct answer:** In thyroid disorders, **Hyperthyroidism** is a classic and frequent cause of AF due to increased sensitivity to catecholamines and direct effects of T3 on the myocardium [1]. Conversely, **Hypothyroidism** is associated with **bradyarrhythmias** (sinus bradycardia) and conduction blocks. While severe hypothyroidism (Myxedema) can rarely cause QT prolongation, it is not a recognized cause of AF. **Analysis of Incorrect Options:** * **Mitral Stenosis (MS):** This is the most common valvular cause of AF. Chronic pressure overload leads to significant left atrial (LA) enlargement and fibrosis, disrupting normal electrical conduction. * **Mitral Regurgitation (MR):** Similar to MS, chronic volume overload in MR leads to LA dilatation, which is a potent substrate for the development of AF. * **Dilated Cardiomyopathy (DCM):** The global enlargement of heart chambers and replacement fibrosis in DCM increase atrial wall stress, making AF a very common complication and a marker of poor prognosis. **NEET-PG High-Yield Pearls:** * **Most common cause of AF (Global):** Hypertension and Coronary Artery Disease. * **Most common valvular cause:** Mitral Stenosis. * **Holiday Heart Syndrome:** AF triggered by acute alcohol consumption. * **Lone AF:** AF occurring in patients <60 years old with no clinical or echocardiographic evidence of cardiopulmonary disease. * **ECG Hallmark:** "Irregularly irregular" rhythm with absent P-waves and presence of f-waves [1].

Question 1

What is the most appropriate intervention for acute myocardial infarction?

Accepted Answer

Early primary coronary intervention

Answer

Streptokinase

Answer

Streptokinase and aspirin

Answer

Streptokinase and heparin

Question 2

What is the abnormality shown in the ECG?

Accepted Answer

Premature ventricular contractions

Answer

Sine wave pattern

Answer

ST segment depression

Answer

Electrical alternans

Question 3

Pulsus bisferiens is seen in all except?

Accepted Answer

Tetralogy of Fallot

Answer

Aortic regurgitation + aortic stenosis

Answer

Aortic regurgitation

Answer

Hypertrophic cardiomyopathy

Question 4

Which of the following arrhythmias is most frequent in Holiday Heart Syndrome?

Accepted Answer

Atrial Fibrillation

Answer

Atrial Flutter

Answer

Ventricular Premature Depolarization

Answer

Ventricular Tachycardia

Question 5

Protein-losing enteropathy is seen in which of the following conditions?

Accepted Answer

Chronic pericarditis

Answer

Tetralogy of Fallot (TOF)

Answer

Hypertrophic Obstructive Cardiomyopathy (HOCM)

Answer

Dilated cardiomyopathy

Question 6

A 73-year-old man has angina pectoris on exertion, but an angiogram reveals noncritical stenosis of the coronary arteries. This clinical presentation is most frequently associated with which of the following valvular heart diseases?

Accepted Answer

Aortic stenosis

Answer

Mitral stenosis

Answer

Mitral insufficiency

Answer

Pulmonary stenosis

Question 7

A patient with acute inferior wall myocardial infarction has developed shock. Which of the following is the most likely cause of shock?

Accepted Answer

Right ventricular infarction

Answer

Cardiac rupture

Answer

Interventricular septal perforation

Answer

Papillary muscle rupture

Question 8

Which of the following is not a major Framingham criterion for heart failure?

Accepted Answer

Hepatomegaly

Answer

Cardiomegaly

Answer

Paroxysmal nocturnal dyspnea

Answer

S3 gallop

Question 9

A 70-year-old man with a past medical history of ischemic heart disease and hypertension presents to his GP with recurrent episodes of syncope over the past 2 weeks. Based upon this ECG, which of the following clinical findings is most likely to be present?

Accepted Answer

Canon A waves

Answer

Absent JVP

Answer

Absent hepato-jugular reflux

Answer

Giant V waves

Question 10

Atrial fibrillation may occur in all of the following conditions, except?

Accepted Answer

Hypothyroidism

Answer

Mitral stenosis

Answer

Dilated cardiomyopathy

Answer

Mitral regurgitation

Cardiology — MCQs

Cardiology — MCQs

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