Cardiology Practice Questions

Q: An otherwise healthy athlete complains of chest pain and dyspnea during routine training, has a double impulse at the apex on examination, and undergoes sudden death. What is the likely diagnosis?

Hypertrophic Obstructive Cardiomyopathy (HOCM). ### **Explanation** The clinical presentation of a young, healthy athlete experiencing exertional chest pain and dyspnea, followed by sudden cardiac death (SCD), is a classic hallmark of **Hypertrophic Obstructive Cardiomyopathy (HOCM)** [1]. **Why HOCM is the Correct Answer:** 1. **Sudden Cardiac Death in Athletes:** HOCM is the most common cause of SCD in young athletes, usually due to ventricular arrhythmias [1], [2]. 2. **Double Impulse at Apex:** This is a pathognomonic finding. The first impulse is a forceful atrial contraction (S4) against a non-compliant ventricle, and the second is the actual ventricular apex beat. 3. **Pathophysiology:** Asymmetrical septal hypertrophy leads to Left Ventricular Outflow Tract (LVOT) obstruction, which worsens during exertion, causing symptoms like angina and syncope [1]. **Analysis of Incorrect Options:** * **Marfan Syndrome:** While associated with SCD, it usually occurs due to **aortic dissection or rupture**. It does not typically present with a double apical impulse. * **Myocardial Infarction (MI):** Rare in young, "otherwise healthy" athletes without significant risk factors or congenital coronary anomalies [2]. * **Valvular Heart Disease:** While Aortic Stenosis can cause exertional symptoms and SCD, it presents with a slow-rising pulse (*pulsus parvus et tardus*) and a single, heaving apex beat, not a double impulse [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Murmur Dynamics:** HOCM features a harsh systolic ejection murmur that **increases** with Valsalva and standing (decreased preload) and **decreases** with squatting or handgrip (increased preload/afterload). * **ECG Findings:** Look for "dagger-like" Q waves in lateral leads (I, aVL, V5-V6). * **Management:** Beta-blockers are the first-line medical therapy; ICD is the definitive treatment for those at high risk of SCD.

Q: In the treatment of severe bradycardia, which of the following is NOT a primary treatment modality?

Diltiazem. The management of symptomatic bradycardia focuses on increasing the heart rate and improving cardiac output. **Why Diltiazem is the Correct Answer:** **Diltiazem** is a non-dihydropyridine Calcium Channel Blocker (CCB). Its primary mechanism involves blocking L-type calcium channels in the SA and AV nodes, which leads to **negative chronotropy** (decreased heart rate) and **negative dromotropy** (slowed conduction). Therefore, Diltiazem is used to treat tachyarrhythmias (like Atrial Fibrillation with RVR) and is strictly **contraindicated** in bradycardia as it would further exacerbate the condition [1]. **Analysis of Other Options:** * **A. Atropine:** The first-line pharmacological treatment for symptomatic bradycardia. It is an anticholinergic that inhibits the vagus nerve, thereby increasing the firing rate of the SA node. * **B. Pacing:** This is the definitive treatment for severe or unstable bradycardia (especially high-grade AV blocks) [2]. It can be Transcutaneous (temporary) or Permanent (pacemaker). * **C. Isoproterenol:** A potent beta-1 and beta-2 adrenergic agonist. It increases heart rate and contractility, serving as a chemical bridge when pacing is unavailable. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice:** Atropine (0.5 mg to 1 mg IV, repeated every 3–5 mins; Max dose: 3 mg). * **Atropine Caution:** It is often ineffective in Mobitz Type II and 3rd-degree AV blocks with wide QRS complexes; in these cases, go straight to pacing [2]. * **Alternative Infusions:** If Atropine fails, consider Dopamine or Epinephrine infusions. * **Paradoxical Effect:** Low doses of Atropine (<0.5 mg) can cause paradoxical bradycardia due to central vagal stimulation.

Q: A 50-year-old male presented to the emergency department with a blood pressure of 160/100 mmHg and a heart rate of 120 bpm. A CECT scan was performed, and the image is provided. What is the management of the condition shown?

Surgical repair. ***Surgical repair*** - **Type A aortic dissection** (involving ascending aorta) requires **emergency surgical repair** to prevent fatal complications like **cardiac tamponade** or **aortic rupture**. - The elevated blood pressure (160/100 mmHg) and tachycardia (120 bpm) are consistent with **acute aortic dissection**, making immediate surgical intervention life-saving. *Low molecular weight heparin* - **Anticoagulation is contraindicated** in aortic dissection as it increases the risk of **extension of dissection** and **hemorrhage**. - LMWH would worsen the **intramural bleeding** and potentially lead to **fatal rupture** of the aortic wall. *Beta blocker medication* - While **beta blockers** are used in **Type B aortic dissection** (descending aorta only) for **blood pressure control**, they are insufficient for Type A dissection. - **Type A dissection** requires surgical intervention regardless of medical management due to high mortality risk without surgery. *Vitamin K inhibitors* - **Warfarin and other vitamin K antagonists** are absolutely contraindicated in acute aortic dissection due to **bleeding risk**. - These medications would promote **hemorrhage into the dissection plane** and increase the likelihood of **aortic rupture** and death.

Q: A patient presents with palpitations. He has no past history of similar episodes but reports consuming a large amount of coffee at work. What is the most appropriate first-line treatment for this patient?

Vagal maneuvers. **Explanation:** The clinical presentation of palpitations following excessive caffeine intake is highly suggestive of **Paroxysmal Supraventricular Tachycardia (PSVT)**, most commonly AV Nodal Reentrant Tachycardia (AVNRT) [1]. Caffeine acts as a sympathomimetic trigger that can initiate these reentrant circuits [1]. **1. Why Vagal Maneuvers are Correct:** According to the ACLS guidelines for stable narrow-complex tachycardia, **vagal maneuvers** (e.g., Valsalva maneuver or carotid sinus massage) are the **first-line intervention**. These maneuvers increase parasympathetic tone and slow conduction through the AV node, which can terminate the reentrant circuit in approximately 20-25% of cases. They are non-invasive, require no equipment, and carry minimal risk in a stable patient. **2. Why Other Options are Incorrect:** * **B. Intravenous Adenosine:** This is the drug of choice and the **second step** if vagal maneuvers fail [1]. It causes a transient AV block to break the circuit. * **C. Catheter Ablation:** This is the definitive/long-term treatment for recurrent PSVT but is never the first-line management for an acute episode. * **D. Cardioversion:** Synchronized DC cardioversion is indicated only if the patient is **hemodynamically unstable** (e.g., hypotension, altered mental status, chest pain, or heart failure). **Clinical Pearls for NEET-PG:** * **Modified Valsalva:** The "Leg-up" Valsalva (blowing into a syringe while supine, followed by passive leg elevation) has a much higher success rate (~43%) than the standard maneuver. * **Adenosine Contraindication:** Avoid adenosine in patients with **Asthma** (can cause bronchospasm) or WPW syndrome with Atrial Fibrillation [1]. * **Drug of Choice for Prevention:** Beta-blockers or Calcium Channel Blockers (Verapamil/Diltiazem) are used for long-term prophylaxis if ablation is not performed.

Q: Cannon 'a' waves in the venous waveform are suggestive of what condition?

AV dissociation. ### Explanation **1. Why AV Dissociation is Correct:** Cannon 'a' waves occur when the right atrium contracts against a **closed tricuspid valve**. In **AV dissociation** (seen in Complete Heart Block or Ventricular Tachycardia), the atria and ventricles beat independently. Occasionally, the right atrium contracts while the right ventricle is in systole (tricuspid valve closed), forcing blood backward into the jugular vein and creating a giant, intermittent 'a' wave. **2. Why the Other Options are Incorrect:** * **Atrial Fibrillation:** In AF, there is no coordinated atrial contraction. Therefore, the **'a' wave is completely absent** in the JVP waveform. * **Tricuspid Regurgitation:** This condition is characterized by a **giant 'v' wave** (or 'cv' wave). As the ventricle contracts, blood leaks back into the atrium, obliterating the 'x' descent and creating a prominent systolic wave. **3. Clinical Pearls for NEET-PG:** * **Regular vs. Irregular Cannon 'a' waves:** * **Regular:** Nodal rhythm (Junctional rhythm), SVT (specifically AVNRT). * **Irregular:** Complete Heart Block (3rd-degree AV block), Ventricular Tachycardia (VT). * **Giant (Prominent) 'a' waves:** These are different from Cannon waves; they occur when the atrium contracts against a *stenosed* valve or *non-compliant* ventricle (e.g., Tricuspid Stenosis, Pulmonary Stenosis, or Right Ventricular Hypertrophy). * **Absent 'y' descent:** Seen in Cardiac Tamponade (distinguish from Constrictive Pericarditis where 'y' is rapid and deep—Friedreich’s sign).

Question 1

An otherwise healthy athlete complains of chest pain and dyspnea during routine training, has a double impulse at the apex on examination, and undergoes sudden death. What is the likely diagnosis?

Accepted Answer

Hypertrophic Obstructive Cardiomyopathy (HOCM)

Answer

Marfan syndrome

Answer

Myocardial Infarction

Answer

Valvular heart disease

Question 2

An elderly man with known ischemic heart disease develops syncope. Peripheral pulses are absent, blood pressure is not recordable, and ECG reveals wide complex tachycardia. What is the immediate management?

Accepted Answer

DC cardioversion

Answer

Thrombolysis with tissue plasminogen activator

Answer

A bolus dose of lidocaine

Answer

IV phenylephrine and carotid sinus pressure

Question 3

Rapid high-frequency fluttering of anterior mitral valve leaflets during systole on 2D ECHO is characteristically seen with which condition?

Accepted Answer

Aortic regurgitation

Answer

Mitral regurgitation

Answer

Tricuspid regurgitation

Answer

Pulmonary regurgitation

Question 4

In the treatment of severe bradycardia, which of the following is NOT a primary treatment modality?

Accepted Answer

Diltiazem

Answer

Atropine

Answer

Pacing

Answer

Isoproterenol

Question 5

The 'a' wave in JVP is seen in which of the following conditions?

Accepted Answer

It will be large when the atria contracts against resistance.

Answer

It represents the filling of the ventricles.

Answer

It is followed by the 'v' wave.

Answer

It decreases during inspiration.

Question 6

A 50-year-old male presented to the emergency department with a blood pressure of 160/100 mmHg and a heart rate of 120 bpm. A CECT scan was performed, and the image is provided. What is the management of the condition shown?

Accepted Answer

Surgical repair

Answer

Low molecular weight heparin

Answer

Beta blocker medication

Answer

Vitamin K inhibitors

Question 7

A patient presents with palpitations. He has no past history of similar episodes but reports consuming a large amount of coffee at work. What is the most appropriate first-line treatment for this patient?

Accepted Answer

Vagal maneuvers

Answer

Intravenous adenosine

Answer

Catheter ablation

Answer

Cardioversion

Question 8

A 26-year-old asymptomatic woman is found to have arrhythmias and a systolic murmur associated with midsystolic clicks. Which investigation would you use?

Accepted Answer

Echocardiography

Answer

Electrophysiological testing

Answer

Thyroid scan

Answer

Angiography

Question 9

An 84-year-old man with a history of smoking and a myocardial infarction 2 years ago presents with chest and leg pain during exercise. His vital signs are temperature, 37.1°C; pulse, 81/min; respirations, 15/min; and blood pressure, 165/100 mm Hg. Peripheral pulses are diminished in the lower extremities. A 7-cm pulsating mass is palpable in the midline of the lower abdomen. Laboratory studies show fasting serum glucose levels of 170 mg/dL and 200 mg/dL. Which of the following vascular lesions is most likely to be present in this patient?

Accepted Answer

Atherosclerotic aneurysm

Answer

Aortic dissection

Answer

Arteriovenous fistula

Answer

Polyarteritis nodosa

Question 10

Cannon 'a' waves in the venous waveform are suggestive of what condition?

Accepted Answer

AV dissociation

Answer

Atrial fibrillation

Answer

Tricuspid regurgitation

Answer

All of the above

Cardiology — MCQs

Cardiology — MCQs

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