Cardiology Practice Questions

Q: A 45-year-old tall, thin male presents with acute onset of chest pain radiating into the back. In the emergency room, his right radial pulse is bounding, but his femoral pulses are absent. What is the most likely diagnosis?

Aortic dissection. The clinical presentation is classic for an **Aortic Dissection (Stanford Type B or DeBakey Type III)** [1]. The patient’s habitus (tall and thin) suggests an underlying connective tissue disorder like **Marfan Syndrome** [2], a major risk factor for aortic pathology [1]. **Why Aortic Dissection is correct:** The hallmark of aortic dissection is sudden, "tearing" or "ripping" chest pain radiating to the back [1]. The pathognomonic sign in this case is the **pulse deficit** (asymmetric pulses). A dissection flap can propagate down the aorta, physically obstructing the orifice of major arterial branches [3]. Here, the flap has likely spared the right subclavian artery (bounding radial pulse) but has occluded the distal aorta or iliac arteries, leading to absent femoral pulses [2]. **Why the other options are incorrect:** * **Aortic Insufficiency:** While a dissection involving the aortic root (Type A) can cause acute AI, it would not explain the absence of femoral pulses [4]. * **Ventricular Fibrillation:** This is a cardiac arrest rhythm leading to sudden collapse and absence of *all* pulses, not a localized pulse deficit. * **Mitral Insufficiency:** Acute MI presents with pulmonary edema and a holosystolic murmur, not back pain or asymmetric pulses. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Digital Subtraction Angiography (DSA), but **CT Angiography** is the investigation of choice in emergency settings [3]. * **Transesophageal Echocardiogram (TEE):** Best for hemodynamically unstable patients [3]. * **Management:** Immediate BP control using **IV Labetalol** (target systolic BP 100–120 mmHg) to reduce shear stress (dP/dt). * **Classification:** Type A (involves ascending aorta) requires surgery; Type B (descending only) is usually managed medically [1].

Q: A 30-year-old male presents with severe chest pain, breathlessness, and hypotension. ECG shows ST elevation in V3, V4, V5, and V6 leads. What is the best treatment for this patient?

Percutaneous Transluminal Coronary Angioplasty (PTCA). ### Explanation **Correct Answer: D. Percutaneous Transluminal Coronary Angioplasty (PTCA)** **Why it is correct:** The patient presents with classic signs of an **Antero-lateral ST-Elevation Myocardial Infarction (STEMI)** (ST elevation in V3-V6) complicated by **cardiogenic shock** (hypotension and breathlessness). According to the current ACC/AHA and ESC guidelines, **Primary Percutaneous Coronary Intervention (PCI/PTCA)** is the gold standard treatment for STEMI [1]. It is superior to fibrinolysis in terms of achieving higher patency rates of the infarct-related artery, lower rates of re-infarction, and reduced intracranial hemorrhage. In patients with hemodynamic instability or cardiogenic shock, PTCA is mandatory regardless of the time delay, as it significantly improves survival [1]. **Why the other options are incorrect:** * **A & B (Streptokinase and t-PA):** These are fibrinolytic agents. While they are used in STEMI if PCI cannot be performed within 120 minutes of medical contact, they are less effective than PTCA. Furthermore, in cardiogenic shock, fibrinolysis is less effective due to poor systemic perfusion [1]. * **C (Heparin):** Heparin is an anticoagulant used as an adjunct therapy in STEMI to prevent further thrombus formation, but it cannot achieve the rapid mechanical reperfusion required to save the myocardium and stabilize the patient. **High-Yield Clinical Pearls for NEET-PG:** * **Door-to-Balloon Time:** Should be **<90 minutes** (at a PCI-capable center) or **<120 minutes** (if transfer is required). * **Door-to-Needle Time (Fibrinolysis):** Should be **<30 minutes**. * **Indications for PTCA over Fibrinolysis:** Cardiogenic shock, contraindications to bleeding, or late presentation (12–24 hours with ongoing ischemia). * **ECG Localization:** V3–V4 (Anterior wall/LAD), V5–V6 (Apex/Lateral/LAD or LCx).

Q: A 55-year-old male with a history of type 2 diabetes mellitus, managed with oral hypoglycemic agents, presents with a blood pressure reading of 164/102 mm Hg. What is the most suitable antihypertensive drug for this patient?

Enalapril. **Explanation:** **1. Why Enalapril is the Correct Choice:** In patients with **Diabetes Mellitus (DM)** and hypertension, **ACE inhibitors (like Enalapril)** or ARBs are the first-line agents of choice. The underlying medical concept is **renoprotection**. Diabetes is a leading cause of chronic kidney disease (Diabetic Nephropathy). ACE inhibitors dilate the efferent arterioles of the glomerulus more than the afferent arterioles, reducing intraglomerular pressure. This action slows the progression of albuminuria and preserves renal function, regardless of the blood pressure-lowering effect. **2. Why the Other Options are Incorrect:** * **Propranolol (Beta-blocker):** Generally avoided as a first-line agent in diabetics because it can mask the autonomic symptoms of hypoglycemia (like tachycardia and tremors) and may impair glucose tolerance by inhibiting insulin release. * **Clonidine (Centrally acting alpha-2 agonist):** This is not a first-line drug for essential hypertension. It is associated with side effects like sedation and dry mouth, and it offers no specific metabolic or renal benefits for diabetic patients. * **Hydrochlorothiazide (Thiazide Diuretic):** While effective, thiazides can cause hyperglycemia (by inhibiting insulin secretion and decreasing peripheral glucose utilization) and hyperlipidemia, making them less ideal than ACE inhibitors for diabetic patients. **Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC):** ACE inhibitors/ARBs are DOC for HTN in patients with DM, Proteinuria, CKD, and Heart Failure. * **Side Effect Profile:** A common side effect of Enalapril is a **dry cough** (due to increased bradykinin). If a patient develops a cough, switch them to an **ARB (e.g., Losartan)**. * **Contraindication:** ACE inhibitors are strictly **contraindicated in pregnancy** (teratogenic) and in patients with **bilateral renal artery stenosis**.

Q: A 65-year-old man is about to undergo an elective hip replacement. A pre-operative ECG is taken. Based upon the ECG, which of the following jugular venous pressure (JVP) abnormalities is most likely to be present?

Absent A waves. ***Absent A waves*** - In **atrial fibrillation**, there is no coordinated **atrial contraction**, resulting in the absence of A waves in the JVP tracing. - The **chaotic atrial activity** prevents the normal atrial systolic contribution to venous return, eliminating the A wave component. *Cannon A waves* - These occur in **complete heart block** or **AV dissociation** when the atria contract against closed tricuspid valves. - They represent **intermittent large A waves** when atrial and ventricular contractions are not synchronized, not seen in atrial fibrillation. *Giant V waves* - These are characteristic of severe **tricuspid regurgitation**, where blood regurgitates back into the right atrium during ventricular systole. - The **enlarged V waves** reflect increased right atrial pressure during systole, unrelated to atrial fibrillation rhythm abnormalities. *Rise in JVP during inspiration* - This describes **Kussmaul's sign**, typically seen in **constrictive pericarditis** or **cardiac tamponade**. - It represents impaired venous return due to **rigid pericardial constraint**, not related to the rhythm disturbance of atrial fibrillation.

Q: A 48-year-old male patient with an anterior myocardial infarction underwent primary angioplasty with a bare metal stent. What duration of antiplatelet therapy will you advise for discharge?

Dual antiplatelets for 12 months, then aspirin long-term. The management of Acute Coronary Syndrome (ACS), such as an ST-Elevation Myocardial Infarction (STEMI), requires **Dual Antiplatelet Therapy (DAPT)** to prevent stent thrombosis and recurrent ischemic events. **1. Why Option A is Correct:** According to current ACC/AHA and ESC guidelines, all patients undergoing Percutaneous Coronary Intervention (PCI) for **ACS** should receive DAPT (Aspirin + a P2Y12 inhibitor like Ticagrelor, Prasugrel, or Clopidogrel) for at least **12 months**, regardless of the stent type (Bare Metal Stent or Drug-Eluting Stent). After 12 months, the P2Y12 inhibitor is typically discontinued, and Aspirin is continued indefinitely for secondary prevention. **2. Why Other Options are Incorrect:** * **Option B & C:** One month of DAPT is insufficient for ACS patients. While 1 month was historically considered for Bare Metal Stents (BMS) in stable ischemic heart disease, the high-risk nature of an **Infarction (ACS)** mandates a full year of therapy to allow for vascular healing and stabilization of other non-culprit plaques. * **Option D:** Monotherapy with Ticagrelor is not the standard of care post-PCI for the first 12 months; Aspirin remains the cornerstone of long-term secondary prevention. **Clinical Pearls for NEET-PG:** * **Stent Type vs. Indication:** In *Stable Ischemic Heart Disease*, DAPT duration depends on stent type (1 month for BMS, 6 months for DES). However, in **ACS**, the duration is always **12 months** regardless of stent type. * **P2Y12 Choice:** In ACS, Ticagrelor or Prasugrel are preferred over Clopidogrel due to superior efficacy, unless there is a high bleeding risk. * **Triple Therapy:** If the patient also has Atrial Fibrillation, they require "Triple Therapy" (DAPT + Oral Anticoagulant), usually for a shortened period (1 week to 1 month) followed by "Double Therapy" [1] to minimize bleeding risk.

Q: A patient in regular rhythm presents with absent P waves on ECG. Leads II, III and aVF reveal a saw-tooth pattern. Which of the following is the most likely diagnosis?

Atrial Flutter with Fixed Block. The presence of a **"saw-tooth" pattern** in the inferior leads (II, III, and aVF) is the pathognomonic ECG finding for **Atrial Flutter** [2]. This pattern represents "F-waves" (flutter waves) caused by a macro-reentrant circuit, typically around the tricuspid valve annulus [2]. The question specifies that the patient is in a **regular rhythm**. In Atrial Flutter, the AV node usually acts as a gatekeeper, allowing only every 2nd, 3rd, or 4th atrial impulse to pass (e.g., 2:1, 3:1, or 4:1 conduction). When this ratio remains constant, it is termed a **Fixed Block**, resulting in a perfectly regular ventricular rate. **Why other options are incorrect:** * **Atrial Fibrillation:** Characterized by an "irregularly irregular" rhythm and the absence of organized P waves or saw-tooth patterns; instead, it shows fine fibrillatory waves [1]. * **Atrial Flutter with Variable Block:** While it shows saw-tooth waves, the changing conduction ratio (e.g., switching between 2:1 and 3:1) would result in an **irregular** rhythm. * **Multifocal Atrial Tachycardia (MAT):** Characterized by at least three different P-wave morphologies and irregular RR intervals, typically seen in COPD patients. **High-Yield Clinical Pearls for NEET-PG:** * **Atrial Rate:** In flutter, the atrial rate is typically **250–350 bpm** [2]. * **Common Presentation:** A narrow QRS tachycardia with a regular heart rate of exactly **150 bpm** is Atrial Flutter with 2:1 block until proven otherwise. * **Treatment of Choice:** For long-term management, **Radiofrequency Ablation** of the cavotricuspid isthmus (CTI) is the definitive treatment with a high success rate [1]. * **Carotid Sinus Massage:** This maneuver increases the AV block, making the underlying saw-tooth waves more visible on ECG, aiding diagnosis.

Q: A 75-year-old man presents with a syncopal episode. He had no incontinence or post-event confusion. Examination reveals a blood pressure of 140/80 mm Hg, pulse of 72/min with no postural changes. His second heart sound is diminished, and there is a systolic ejection murmur that radiates to the carotids. The Valsalva maneuver decreases the murmur's length and intensity. What is the most likely diagnosis for this patient's systolic murmur?

aortic stenosis. **Explanation:** The clinical presentation of **syncope**, a **diminished second heart sound (S2)**, and a **systolic ejection murmur radiating to the carotids** [1] is classic for **Aortic Stenosis (AS)**. In elderly patients, AS is most commonly due to senile calcification [2]. **Why Aortic Stenosis is correct:** * **Murmur Characteristics:** It is a crescendo-decrescendo systolic murmur heard best at the right second intercostal space. Radiation to the carotids (carotid shudder) is a hallmark [1]. * **S2 Changes:** As the valve becomes more calcified and immobile, the aortic component of the second heart sound (A2) decreases in intensity [1]. * **Valsalva Maneuver:** This maneuver decreases venous return (preload). In AS, reduced preload leads to less blood flowing across the stenotic valve [3], thereby **decreasing** the murmur's intensity. **Why other options are incorrect:** * **HOCM:** While HOCM also presents with a systolic ejection murmur and syncope, the murmur **increases** in intensity with Valsalva (due to decreased LV volume increasing outflow obstruction) [3]. It typically does not radiate to the carotids. * **Mitral Regurgitation (MR):** MR presents with a **holosystolic** (pansystolic) murmur heard best at the apex radiating to the axilla, not an ejection murmur radiating to the carotids. * **Tricuspid Regurgitation (TR):** TR is a holosystolic murmur heard at the left lower sternal border that **increases with inspiration** (Carvallo's sign). **NEET-PG High-Yield Pearls:** * **SAD Triad of AS:** **S**yncope, **A**ngina, and **D**yspnea (indicates heart failure). * **Pulsus Parvus et Tardus:** A small-amplitude, delayed carotid pulse is a classic sign of severe AS. * **Dynamic Auscultation:** Most murmurs decrease with Valsalva/Standing (decreased preload) **EXCEPT** HOCM and Mitral Valve Prolapse (MVP), which increase [3].

Q: A 36-year-old male presents with a 2-day history of continuous chest pain that does not change with activity. Vital signs reveal normal blood pressure, mild tachycardia and tachypnea, and an oxygen saturation of 90% on room air. The cardiopulmonary examination is normal. An ECG shows a rate of 106 beats/min, left axis deviation, left ventricular hypertrophy, PR depression, and T wave inversions in V2 to V5. Troponin and CPK-MB are minimally elevated. What is the most likely diagnosis?

Pericarditis. **Explanation:** The clinical presentation and ECG findings point toward **Acute Pericarditis**. **1. Why Pericarditis is correct:** The patient presents with continuous chest pain and classic ECG markers. **PR segment depression** is considered a highly specific (though not always sensitive) sign of acute pericarditis, representing atrial injury [1]. While the T-wave inversions in V2-V5 and minimal biomarker elevation (Troponin/CPK-MB) might suggest ischemia, they are also common in **myopericarditis** (pericarditis with myocardial involvement) [1]. The absence of dynamic changes with activity and the presence of PR depression are the key discriminators here. **2. Why the other options are incorrect:** * **Pulmonary Embolism (PE):** While PE causes tachycardia, tachypnea, and hypoxia (90% SpO2), the ECG typically shows sinus tachycardia or the S1Q3T3 pattern. PR depression is not a feature of PE. * **Costochondritis:** This causes localized chest wall tenderness (musculoskeletal). It would not cause hypoxia, tachycardia, or ECG/biomarker abnormalities. * **Unstable Angina:** This typically presents with exertional chest pain or pain at rest with ST-segment depressions or T-wave inversions [2]. However, it does not cause PR depression or hypoxia, and by definition, biomarkers remain normal in unstable angina (elevated troponins indicate NSTEMI) [2]. **NEET-PG High-Yield Pearls:** * **ECG Stages of Pericarditis:** Stage 1 (Diffuse ST elevation & PR depression) → Stage 2 (Normalization) → Stage 3 (T-wave inversion) → Stage 4 (Normalization) [1]. * **SpO2 in Pericarditis:** While hypoxia is unusual for simple pericarditis, it can occur if there is significant pleuritic pain leading to splinting/hypoventilation or associated pulmonary pathology. * **Gold Standard:** PR depression in limb leads (especially II, aVF, V5-V6) and PR elevation in aVR are diagnostic hallmarks [1].

Question 1

A 45-year-old tall, thin male presents with acute onset of chest pain radiating into the back. In the emergency room, his right radial pulse is bounding, but his femoral pulses are absent. What is the most likely diagnosis?

Accepted Answer

Aortic dissection

Answer

Aortic insufficiency

Answer

Ventricular fibrillation

Answer

Mitral insufficiency

Question 2

A 30-year-old male presents with severe chest pain, breathlessness, and hypotension. ECG shows ST elevation in V3, V4, V5, and V6 leads. What is the best treatment for this patient?

Accepted Answer

Percutaneous Transluminal Coronary Angioplasty (PTCA)

Answer

Streptokinase

Answer

t-PA

Answer

Heparin

Question 3

A 55-year-old male with a history of type 2 diabetes mellitus, managed with oral hypoglycemic agents, presents with a blood pressure reading of 164/102 mm Hg. What is the most suitable antihypertensive drug for this patient?

Accepted Answer

Enalapril

Answer

Propranolol

Answer

Clonidine

Answer

Hydrochlorothiazide

Question 4

A 65-year-old man is about to undergo an elective hip replacement. A pre-operative ECG is taken. Based upon the ECG, which of the following jugular venous pressure (JVP) abnormalities is most likely to be present?

Accepted Answer

Absent A waves

Answer

Cannon A waves

Answer

Giant V waves

Answer

Rise in JVP during inspiration

Question 5

A 48-year-old male patient with an anterior myocardial infarction underwent primary angioplasty with a bare metal stent. What duration of antiplatelet therapy will you advise for discharge?

Accepted Answer

Dual antiplatelets for 12 months, then aspirin long-term

Answer

Ticagrelor for 1 month, then aspirin long-term

Answer

Aspirin for 1 month, then ticagrelor long-term

Answer

Ticagrelor alone is adequate long-term

Question 6

A patient in regular rhythm presents with absent P waves on ECG. Leads II, III and aVF reveal a saw-tooth pattern. Which of the following is the most likely diagnosis?

Accepted Answer

Atrial Flutter with Fixed Block

Answer

Atrial Fibrillation

Answer

Atrial Flutter with Variable Block

Answer

Multifocal Atrial Tachycardia

Question 7

Infective endocarditis is common in which of the following conditions?

Accepted Answer

Mitral stenosis

Answer

Mitral regurgitation

Answer

Coarctation of aorta

Answer

Aortic regurgitation

Question 8

What is the commonest congenital lesion complicated by infective endocarditis?

Accepted Answer

Ventricular Septal Defect (VSD)

Answer

Atrial Septal Defect (ASD)

Answer

Patent Ductus Arteriosus (PDA)

Answer

Tetralogy of Fallot (TOF)

Question 9

A 75-year-old man presents with a syncopal episode. He had no incontinence or post-event confusion. Examination reveals a blood pressure of 140/80 mm Hg, pulse of 72/min with no postural changes. His second heart sound is diminished, and there is a systolic ejection murmur that radiates to the carotids. The Valsalva maneuver decreases the murmur's length and intensity. What is the most likely diagnosis for this patient's systolic murmur?

Accepted Answer

aortic stenosis

Answer

hypertrophic obstructive cardiomyopathy (HOCM)

Answer

mitral regurgitation (chronic)

Answer

tricuspid regurgitation

Question 10

A 36-year-old male presents with a 2-day history of continuous chest pain that does not change with activity. Vital signs reveal normal blood pressure, mild tachycardia and tachypnea, and an oxygen saturation of 90% on room air. The cardiopulmonary examination is normal. An ECG shows a rate of 106 beats/min, left axis deviation, left ventricular hypertrophy, PR depression, and T wave inversions in V2 to V5. Troponin and CPK-MB are minimally elevated. What is the most likely diagnosis?

Accepted Answer

Pericarditis

Answer

Pulmonary embolism

Answer

Costochondritis

Answer

Unstable angina

Cardiology — MCQs

Cardiology — MCQs

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