Cardiology Practice Questions

Q: A 62-year-old man presents with symptoms of shortness of breath, worse with exertion and difficulty lying down. He reports no chest pain or palpitations but his feet are swollen. His past medical history includes hypertension and type 2 diabetes, for which he is taking ramipril, amlodipine, and metformin. On physical examination, the blood pressure is 125/84 mm Hg, heart rate is 100/min. The jugular venous pressure is 8 cm above the sternal angle, with a third heart sound, pedal edema, and bibasilar crackles on auscultation of the lungs. Which one of the following may be implicated in fluid retention for this condition?

Increased aldosterone. **Explanation:** The clinical presentation of dyspnea, orthopnea, elevated JVP, S3 gallop, pedal edema, and bibasilar crackles [1] is diagnostic of **Congestive Heart Failure (CHF)** [2]. In CHF, the primary driver of fluid retention is the activation of the **Renin-Angiotensin-Aldosterone System (RAAS)** [1]. 1. **Why Option B is Correct:** In heart failure, decreased cardiac output leads to reduced renal perfusion. This triggers the release of Renin, which converts Angiotensinogen to Angiotensin I. Angiotensin-Converting Enzyme (ACE) then produces Angiotensin II, which stimulates the adrenal cortex to secrete **Aldosterone**. Aldosterone acts on the distal tubules and collecting ducts to increase **sodium and water reabsorption**, leading to fluid overload and edema [1]. 2. **Why Other Options are Incorrect:** * **Decreased Renin:** In CHF, renin is significantly **increased** to compensate for low effective arterial blood volume [1]. * **Increased Estrogen:** While estrogen can cause mild sodium retention (e.g., premenstrual bloating), it is not the pathological mechanism behind heart failure-induced edema. * **Increased Growth Hormone:** GH excess (Acromegaly) can cause cardiomyopathy, but it is not the direct mediator of fluid retention in standard CHF. **NEET-PG High-Yield Pearls:** * **S3 Gallop:** The most specific physical sign for heart failure in adults (indicates ventricular filling into a dilated, compliant chamber). * **Spironolactone/Eplerenone:** These Aldosterone antagonists are "disease-modifying" drugs in HFrEF that reduce mortality by preventing myocardial fibrosis and fluid retention. * **BNP (B-type Natriuretic Peptide):** Released from ventricles due to stretch; it acts as a natural antagonist to the RAAS system by promoting natriuresis [1].

Q: What is the investigation of choice to confirm hemochromatosis as the cause of cardiomyopathy?

MRI. **Explanation:** **Why MRI is the Correct Answer:** Cardiac MRI (specifically **T2* weighted imaging**) is the gold standard and investigation of choice for confirming and quantifying myocardial iron overload in hemochromatosis. Iron is paramagnetic; its deposition in the myocardium causes a shortening of the T2* relaxation time. A T2* value of **<20 ms** indicates iron overload, while **<10 ms** signifies a high risk of developing heart failure. MRI is non-invasive, more sensitive than biopsy (due to the patchy nature of iron deposition), and is used to monitor the efficacy of chelation therapy. In terms of imaging techniques, MRI has high specificity for iron overload [1]. **Why Other Options are Incorrect:** * **ECG:** While it may show non-specific ST-T wave changes, low voltage complexes, or arrhythmias (like supraventricular tachycardia), it cannot confirm the underlying etiology of iron deposition. * **Echocardiogram:** This is the initial screening tool to assess functional status. It typically shows a **restrictive cardiomyopathy** pattern (early stage) or **dilated cardiomyopathy** (late stage), but it cannot differentiate iron overload from other causes of infiltrative cardiomyopathy. * **CT Scan:** CT has poor sensitivity for detecting myocardial iron compared to MRI and involves unnecessary ionizing radiation. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad (Bronze Diabetes):** Cirrhosis, Diabetes Mellitus, and Skin Hyperpigmentation. * **Cardiac Involvement:** Hemochromatosis is a unique cause of "reversible" cardiomyopathy if iron is removed via phlebotomy or chelation. * **Histology:** On biopsy, iron is visualized using **Prussian Blue stain** [1]. * **Screening:** The most sensitive initial lab test is **Transferrin Saturation** (>45%); the most useful screening protein is **Serum Ferritin** [1].

Q: Reperfusion is believed to restore contractile function of which of the following?

Hibernating Myocardium. ### Explanation The correct answer is **Hibernating Myocardium**. **1. Why Hibernating Myocardium is Correct:** Hibernating myocardium refers to a state of **chronic** but reversible left ventricular systolic dysfunction due to persistently reduced coronary blood flow (chronic ischemia) [1]. In this state, the myocytes remain viable but "downregulate" their metabolism and contractility to match the low oxygen supply, preventing irreversible necrosis [1]. The hallmark of hibernation is that **contractile function improves or is restored after reperfusion** (e.g., via CABG or PCI), provided intervention occurs before irreversible damage [2]. **2. Why the Other Options are Incorrect:** * **Stunned Myocardium (Option A):** This is a state of temporary contractile dysfunction that persists **after** blood flow has already been restored (post-ischemic dysfunction). Unlike hibernation, the blood flow is already normal, but the muscle takes time to recover. Reperfusion is the *cause* of the recovery process, not the trigger for restoration of function, as the flow is already present. * **Ischemic/Non-ischemic bled myocardium (Options C & D):** These terms are not standard clinical descriptors for reversible myocardial dysfunction. "Bled" (hemorrhagic) myocardium usually implies severe microvascular injury or reperfusion injury, which often leads to permanent damage rather than functional restoration. **3. NEET-PG Clinical Pearls:** * **Gold Standard for Viability:** PET scan (showing FDG uptake) is the gold standard to differentiate hibernating (viable) from infarcted (non-viable) tissue. * **Dobutamine Stress Echo:** Hibernating myocardium shows a **biphasic response** (improvement at low doses, worsening at high doses). * **Key Distinction:** * **Stunning:** Flow is normal; function is low (temporary). * **Hibernation:** Flow is low; function is low (reversible upon revascularization).

Q: A 26-year-old man attends an occupational health assessment. A 12-lead ECG is recorded. He is feeling well and has no symptoms or significant past medical history. Based on the ECG findings, what is the most likely diagnosis?

Wolff-Parkinson White Syndrome. ***Wolff-Parkinson White Syndrome*** - Classic **ECG triad** includes **short PR interval** ( 120ms) due to ventricular pre-excitation via an **accessory pathway**. - Often discovered **incidentally** in asymptomatic young individuals during routine screening, as the **accessory pathway** allows early ventricular activation bypassing the normal AV node conduction delay. *Right Bundle Branch Block* - Characterized by **wide QRS** (>120ms) with **RSR' pattern** in V1-V2 and **wide S waves** in leads I and V6, but **no delta wave** present. - Maintains **normal PR interval** and lacks the characteristic **slurred upstroke** seen in pre-excitation syndromes. *Brugada Syndrome* - Distinguished by **coved ST elevation** in leads V1-V2 with **downsloping ST segments**, not delta waves or short PR intervals. - Associated with **sodium channel mutations** and risk of **ventricular arrhythmias**, but ECG shows normal PR interval and narrow QRS when not in arrhythmia. *Normal Variant* - Would show **normal PR interval** (120-200ms), **narrow QRS complex** (<120ms), and **absence of delta waves**. - Lacks any of the characteristic pre-excitation findings that suggest an **accessory pathway** or conduction abnormality.

Q: Which of the following investigations can detect the volume of infarcted area in acute myocardial infarction?

Echocardiography. The correct answer is **Echocardiography (Option A)**. In the setting of acute myocardial infarction (AMI), Echocardiography is the most practical bedside tool to assess the **volume and extent of the infarcted area** [1]. It detects regional wall motion abnormalities (RWMA) that occur almost immediately after coronary occlusion. By visualizing which segments of the myocardium are hypokinetic, akinetic, or dyskinetic, clinicians can estimate the "area at risk" and the total volume of functional loss. **Why other options are incorrect:** * **Electrocardiography (ECG):** While ECG is the gold standard for initial diagnosis and localization (e.g., Anterior vs. Inferior), it reflects electrical changes rather than physical volume [2]. It cannot precisely quantify the cubic volume of infarcted tissue. * **CPK-MB:** Cardiac enzymes correlate with the *magnitude* of myocardial necrosis, but they provide a biochemical estimate rather than a spatial or volumetric measurement of the infarct. * **Thallium Scan:** Thallium-201 is a "cold spot" scan used primarily for assessing myocardial viability and perfusion. While it can show areas of decreased uptake, it is rarely used in the *acute* phase to measure infarct volume due to its logistical complexity compared to Echo. **NEET-PG High-Yield Pearls:** * **Echo in AMI:** The earliest sign of ischemia on Echo is systolic wall thinning and reduced inward motion (RWMA) [1]. * **Gold Standard:** While Echo is the practical choice, **Cardiac MRI (Delayed Gadolinium Enhancement)** is the most accurate "Gold Standard" for quantifying infarct size and transmurality [3]. * **Negative Predictive Value:** A normal Echocardiogram during active chest pain has a very high negative predictive value for ruling out a large MI.

Q: All of the following can occur in rheumatic fever except?

Loud first heart sound. **Explanation:** The correct answer is **Loud first heart sound (S1)** because, in the **acute phase** of Rheumatic Fever (RF), the S1 is typically **soft or muffled**, not loud. **1. Why "Loud S1" is the correct choice (The Exception):** Acute Rheumatic Fever causes **pancarditis** [1]. Inflammation of the myocardium (myocarditis) leads to a prolonged PR interval (First-degree AV block). A prolonged PR interval allows the mitral valve leaflets to float back toward a semi-closed position before ventricular systole begins, resulting in a **soft S1**. Additionally, acute mitral regurgitation (common in RF) [2] further softens the S1. A *loud* S1 is a hallmark of chronic, calcified Mitral Stenosis, not the acute inflammatory phase of RF. **2. Analysis of Incorrect Options:** * **Mitral Regurgitation (MR):** This is the **most common** valvular abnormality in acute rheumatic carditis [2]. It occurs due to annular dilatation or chordal inflammation, presenting as a pansystolic murmur at the apex. * **Mitral Stenosis (MS):** While MS is a **chronic** sequela of rheumatic heart disease (occurring years later), the question asks what *can* occur in rheumatic fever (encompassing the disease spectrum). However, in the acute phase, a "Carey Coombs murmur" (a mid-diastolic murmur) can mimic MS due to valvulitis. * **Pericarditis:** As part of the **pancarditis** (endocarditis, myocarditis, and pericarditis) [1], patients can develop pericardial friction rubs or effusions. **Clinical Pearls for NEET-PG:** * **Most common valve involved:** Mitral > Aortic > Tricuspid > Pulmonary. * **Carey Coombs Murmur:** A short, mid-diastolic murmur heard in acute RF due to mitral valve leaflet edema (distinguish from the opening snap of chronic MS). * **Jones Criteria:** Remember that Carditis is a **Major** criterion, while a prolonged PR interval is a **Minor** criterion.

Q: A 70-year-old male with a history of hypertension and diabetes mellitus presents with the following rhythm, accompanied by a blood pressure of 90/40 mm Hg and a feeble pulse. What is the next step in management?

DC cardioversion. ***DC cardioversion*** - The patient presents with **hemodynamic instability** (BP 90/40 mmHg, feeble pulse) requiring **immediate electrical cardioversion** per ACLS guidelines. - **Synchronized DC cardioversion** is the first-line treatment for any **hemodynamically unstable tachyarrhythmia** regardless of rhythm type. *IV adenosine* - **Adenosine** is used for stable patients with **narrow-complex SVT** and requires hemodynamic stability for safe administration. - In **hemodynamically unstable** patients, pharmacological agents delay definitive treatment and can worsen hypotension. *IV diltiazem* - **Diltiazem** is a calcium channel blocker used for **rate control** in stable atrial fibrillation or atrial flutter. - It can cause **further hypotension** and is contraindicated in hemodynamically unstable patients. *Ibutilide* - **Ibutilide** is used for **chemical cardioversion** of atrial fibrillation/flutter in hemodynamically stable patients. - It requires **continuous cardiac monitoring** and is inappropriate when immediate intervention is needed for instability.

Question 1

A 62-year-old man presents with symptoms of shortness of breath, worse with exertion and difficulty lying down. He reports no chest pain or palpitations but his feet are swollen. His past medical history includes hypertension and type 2 diabetes, for which he is taking ramipril, amlodipine, and metformin. On physical examination, the blood pressure is 125/84 mm Hg, heart rate is 100/min. The jugular venous pressure is 8 cm above the sternal angle, with a third heart sound, pedal edema, and bibasilar crackles on auscultation of the lungs. Which one of the following may be implicated in fluid retention for this condition?

Accepted Answer

Increased aldosterone

Answer

Decreased renin

Answer

Increased estrogen

Answer

Increased growth hormone

Question 2

What is the investigation of choice to confirm hemochromatosis as the cause of cardiomyopathy?

Accepted Answer

MRI

Answer

ECG

Answer

Echocardiogram

Answer

CT Scan

Question 3

Reperfusion is believed to restore contractile function of which of the following?

Accepted Answer

Hibernating Myocardium

Answer

Stunned Myocardium

Answer

Ischemic non-bled myocardium

Answer

Non ischemic bled myocardium

Question 4

A 71-year-old man presents with blurry vision and blood-tinged urine. He has a history of hypertension treated with a beta-blocker, an ACE inhibitor, and a calcium channel blocker. His symptoms began 3 days ago when he stopped his medications. His blood pressure is 200/110 mmHg, funduscopic examination reveals flame hemorrhages and papilledema, and urinalysis shows red blood cells with dysmorphic red blood cell casts. He has an abdominal bruit. What is the most appropriate next step in management?

Accepted Answer

Administer intravenous medication to reduce his blood pressure.

Answer

Order an ECG and observe the patient.

Answer

Order an abdominal CT scan to rule out aortic aneurysm.

Answer

Administer the patient's usual daily doses of blood pressure medications and observe him.

Question 5

Which of the following is a criterion for cardiac shock?

Accepted Answer

Systolic blood pressure < 90 mm Hg

Answer

Diastolic blood pressure < 80 mm Hg

Answer

Cardiac index < 3.5 L/min/m

Answer

Stroke volume 70 ml

Question 6

A 26-year-old man attends an occupational health assessment. A 12-lead ECG is recorded. He is feeling well and has no symptoms or significant past medical history. Based on the ECG findings, what is the most likely diagnosis?

Accepted Answer

Wolff-Parkinson White Syndrome

Answer

Right Bundle Branch Block

Answer

Brugada Syndrome

Answer

Normal Variant

Question 7

Which of the following investigations can detect the volume of infarcted area in acute myocardial infarction?

Accepted Answer

Echocardiography

Answer

Electrocardiography

Answer

Levels of Creatine Phosphokinase-MB

Answer

Thallium scan

Question 8

Brugada syndrome is associated with which of the following ECG findings?

Accepted Answer

Right Bundle Branch Block

Answer

Left Bundle Branch Block

Answer

Left Anterior Fascicular block

Answer

Left Posterior Fascicular block

Question 9

All of the following can occur in rheumatic fever except?

Accepted Answer

Loud first heart sound

Answer

Mitral regurgitation

Answer

Mitral stenosis

Answer

Pericarditis

Question 10

A 70-year-old male with a history of hypertension and diabetes mellitus presents with the following rhythm, accompanied by a blood pressure of 90/40 mm Hg and a feeble pulse. What is the next step in management?

Accepted Answer

DC cardioversion

Answer

IV adenosine

Answer

IV diltiazem

Answer

Ibutilide

Cardiology — MCQs

Cardiology — MCQs

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