Cardiology Practice Questions

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: What causes Wolff-Parkinson-White syndrome?

Right-sided accessory pathway. **Explanation:** **Wolff-Parkinson-White (WPW) syndrome** is a pre-excitation syndrome caused by the presence of an **accessory conduction pathway** (known as the **Bundle of Kent**) that bypasses the normal atrioventricular (AV) node [1]. This pathway directly connects the atria and the ventricles. While these pathways can be left-sided, right-sided, or septal, the presence of an accessory pathway is the fundamental anatomical defect [1], [3]. In the context of this question, a **right-sided accessory pathway** (Option B) correctly identifies the underlying mechanism of pre-excitation. **Why other options are incorrect:** * **Options A & D (Bundle Branch Blocks):** These represent delays or blocks in the normal conduction system (His-Purkinje system) below the AV node. They cause widening of the QRS complex but do not involve an accessory pathway or the characteristic "delta wave" seen in WPW. * **Option C (Ectopic pacemaker):** This refers to an abnormal site of impulse generation (like in Atrial Tachycardia). WPW is a disorder of **conduction**, not necessarily impulse generation, though it can lead to re-entrant tachycardias [2]. **High-Yield Clinical Pearls for NEET-PG:** 1. **ECG Triad:** Short PR interval (<0.12s), Delta wave (slurred upstroke of QRS), and wide QRS complex [1]. 2. **Type A vs. Type B:** Type A (Left-sided pathway) shows positive delta waves in all precordial leads (dominant R in V1). Type B (Right-sided pathway) shows negative delta waves in V1 and V2. 3. **Associated Condition:** WPW is frequently associated with **Ebstein’s Anomaly** (usually right-sided pathways). 4. **Management:** **Radiofrequency ablation** is the definitive treatment. In acute orthodromic tachycardia, use Adenosine [3]; in AF with WPW, avoid AV nodal blockers (ABCD: Adenosine, Beta-blockers, Calcium channel blockers, Digoxin) as they can precipitate ventricular fibrillation.

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: A 49-year-old man has his serum lipids measured. Which pattern suggests the lowest risk for coronary artery disease?

Total cholesterol 202 mg/dL, HDL cholesterol 45 mg/dL. The risk of coronary artery disease (CAD) is not determined by total cholesterol alone but by the balance between atherogenic lipoproteins and protective ones [1]. The most reliable predictor among the given options is the **Total Cholesterol to HDL ratio (TC/HDL ratio)** [3]. A lower ratio indicates a lower cardiovascular risk. **1. Why Option D is Correct:** In Option D, the TC/HDL ratio is **4.48** (202/45). This is the lowest ratio among all choices. Furthermore, an HDL level >40 mg/dL in men is considered protective, whereas levels <40 mg/dL are independent risk factors for CAD [2]. Option D provides the best combination of a near-optimal total cholesterol and the highest HDL level. **2. Analysis of Incorrect Options:** * **Option A:** Ratio = **7.67** (215/28). This represents the highest risk due to high total cholesterol and very low HDL (well below the 40 mg/dL threshold). * **Option B:** Ratio = **5.0** (215/43). While the HDL is acceptable, the total cholesterol is higher than in Option D, leading to a higher overall ratio. * **Option C:** Ratio = **6.20** (180/29). Despite having the lowest total cholesterol, the very low HDL (29 mg/dL) significantly increases the risk, resulting in a worse ratio than Option D. **High-Yield Clinical Pearls for NEET-PG:** * **The "Good" vs. "Bad":** HDL is anti-atherogenic (removes cholesterol from foam cells via reverse cholesterol transport), while LDL is pro-atherogenic [1]. * **Target Ratios:** A TC/HDL ratio ** 5.0** indicates high risk [3]. * **Non-HDL Cholesterol:** Calculated as (Total Cholesterol - HDL). It is often a better predictor of risk than LDL alone, especially in patients with high triglycerides. * **Negative Risk Factor:** An HDL level **≥60 mg/dL** is considered a "negative" risk factor, meaning it removes one risk factor from the total cardiovascular risk profile.

Q: A Carey coomb murmur is heard in which of the following conditions?

Acute rheumatic carditis. The **Carey Coombs murmur** is a classic clinical sign of **Acute Rheumatic Carditis** [1]. It is a short, mid-diastolic murmur heard best at the apex. **Why it occurs:** During the acute phase of rheumatic fever, inflammation of the endocardium (valvulitis) leads to edema and thickening of the mitral valve leaflets [3]. This creates a functional (relative) stenosis. As blood flows from the left atrium to the left ventricle during the rapid filling phase of diastole, the turbulent flow across these swollen leaflets produces the murmur. Unlike the murmur of permanent Mitral Stenosis, it is transient and disappears as the acute inflammation subsides. **Analysis of Incorrect Options:** * **A. Constrictive Pericarditis:** Characterized by a **Pericardial Knock** (an early diastolic sound) due to the sudden cessation of ventricular filling by a rigid pericardium. * **C. Cardiomyopathy:** Hypertrophic cardiomyopathy (HCM) typically presents with a harsh systolic ejection murmur [2], while Dilated Cardiomyopathy may present with a soft pansystolic murmur due to secondary Mitral Regurgitation. * **D. Cardiac Tamponade:** Classically associated with **Beck’s Triad** (hypotension, JVD, and muffled heart sounds). Murmurs are generally absent. **NEET-PG High-Yield Pearls:** * **Carey Coombs vs. Mitral Stenosis:** Carey Coombs lacks an opening snap and a loud S1, which are hallmarks of chronic rheumatic mitral stenosis [2]. * **Jones Criteria:** Carditis is a major criterion for diagnosing Acute Rheumatic Fever [1]. * **Austin Flint Murmur:** A mid-diastolic murmur heard in severe **Aortic Regurgitation** (due to the regurgitant jet displacing the mitral leaflet). * **Graham Steell Murmur:** An early diastolic murmur of **Pulmonary Regurgitation** secondary to pulmonary hypertension.

Q: What is not true about infective endocarditis?

Rose spots. Infective Endocarditis (IE) is a multisystem disease characterized by infection of the endocardial surface, typically the heart valves. The clinical manifestations result from three processes: local destructive infection, septic embolization, and circulating immune complexes. **Why "Rose spots" is the correct answer:** Rose spots are small, blanching, rose-colored maculopapules found on the chest or abdomen. They are pathognomonic for **Enteric (Typhoid) Fever**, caused by *Salmonella typhi*. They are not a feature of infective endocarditis. **Analysis of incorrect options:** * **Hematuria:** This is a common finding in IE [1]. It can occur due to **embolic renal infarction** or, more characteristically, due to **immune-complex mediated glomerulonephritis** (a classic "immunological phenomenon" in Duke’s criteria). * **Roth spots:** These are retinal hemorrhages with central pale spots (white centers) caused by immune complex-mediated vasculitis [3]. They are one of the minor Duke’s criteria. * **Hemiplegia:** Neurological complications occur in up to 40% of cases [1]. Hemiplegia typically results from **septic emboli** originating from vegetations (especially from the mitral valve) leading to an ischemic stroke or a ruptured mycotic aneurysm. **High-Yield Clinical Pearls for NEET-PG:** * **Duke’s Criteria:** Remember that "Immunological phenomena" include Roth spots, Osler nodes, and Glomerulonephritis [3]. "Vascular phenomena" include Janeway lesions, Mycotic aneurysms, and Septic emboli. * **Osler Nodes vs. Janeway Lesions:** Osler nodes are **Painful** (Ouch!) and immunologic; Janeway lesions are **Painless** and embolic. * **Most common cause:** *Staphylococcus aureus* is now the most common cause of acute IE globally and in IV drug users [2]. *Viridans streptococci* remain common in subacute cases following dental procedures.

Q: What is true regarding cardiomyopathy?

All of the above. **Explanation:** Cardiomyopathy refers to a heterogeneous group of diseases of the myocardium associated with mechanical and/or electrical dysfunction. The question refers to the clinical features and etiologies of **Dilated Cardiomyopathy (DCM)**, the most common form [1]. * **Option A (RV dilatation):** In DCM, there is progressive cardiac remodeling leading to the dilatation of both the left and right ventricles [1]. While it often begins in the LV, biventricular involvement is a hallmark of advanced disease, leading to systolic dysfunction and heart failure. * **Option B (Thyrotoxicosis):** Endocrine disorders are known secondary causes of DCM. Hyperthyroidism (thyrotoxicosis) induces a hyperdynamic state that can lead to "high-output heart failure" and eventually tachycardia-induced cardiomyopathy. * **Option C (Alcohol):** Chronic alcohol consumption is one of the most common causes of secondary (acquired) DCM [1]. It exerts a direct toxic effect on the myocardium and may be exacerbated by associated nutritional deficiencies (e.g., Thiamine/B1 deficiency leading to Wet Beriberi). Since all three statements accurately describe aspects of cardiomyopathy, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of DCM:** Idiopathic (followed by genetic mutations like *TTN* encoding Titin) [1]. * **Reversibility:** Alcohol-induced cardiomyopathy and Tachycardia-induced cardiomyopathy (including thyrotoxicosis) are potentially reversible if the underlying cause is treated early. * **Diagnosis:** Echocardiography is the gold standard, showing an Ejection Fraction (EF) <40% and increased ventricular volumes. * **Peripartum Cardiomyopathy:** A specific form of DCM occurring in the last month of pregnancy or within 5 months postpartum.

Question 1

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 2

What causes Wolff-Parkinson-White syndrome?

Accepted Answer

Right-sided accessory pathway

Answer

Bundle branch block

Answer

Ectopic pacemaker in the atrium

Answer

Left bundle branch block

Question 3

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

Accepted Answer

Autosomal recessive inheritance

Answer

Myocyte disarray

Answer

Diastolic failure

Answer

Bifid pulse

Question 4

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 5

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 6

Aggravation of symptoms of angina in a patient when given nitrates is seen in which of the following conditions?

Accepted Answer

Idiopathic hypertrophic subaortic stenosis

Answer

Aortic regurgitation

Answer

Mitral regurgitation

Answer

Single left coronary artery stenosis

Question 7

A 49-year-old man has his serum lipids measured. Which pattern suggests the lowest risk for coronary artery disease?

Accepted Answer

Total cholesterol 202 mg/dL, HDL cholesterol 45 mg/dL

Answer

Total cholesterol 215 mg/dL, high-density lipoprotein (HDL) cholesterol 28 mg/dL

Answer

Total cholesterol 215 mg/dL, HDL cholesterol 43 mg/dL

Answer

Total cholesterol 180 mg/dL, HDL cholesterol 29 mg/dL

Question 8

A Carey coomb murmur is heard in which of the following conditions?

Accepted Answer

Acute rheumatic carditis

Answer

Constrictive pericarditis

Answer

Cardiomyopathy

Answer

Cardiac tamponade

Question 9

What is not true about infective endocarditis?

Accepted Answer

Rose spots

Answer

Hematuria

Answer

Roth spots

Answer

Hemiplegia

Question 10

What is true regarding cardiomyopathy?

Accepted Answer

All of the above

Answer

RV dilatation is present

Answer

May result from thyroxicosis

Answer

Secondary to alcohol

Cardiology — MCQs

Cardiology — MCQs

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