Cardiology Practice Questions

Q: In a patient with a history of recurrent syncope, a Holter recording shows a QT interval of 680 msec. Which disease is suspected in this patient?

Long QT syndrome. **Explanation:** **1. Why Long QT Syndrome (LQTS) is correct:** The hallmark of LQTS is the prolongation of the QT interval on the ECG, representing delayed ventricular repolarization [1]. The normal QTc (corrected QT) is typically 500 msec is considered high risk). This delay predisposes patients to **Torsades de Pointes (TdP)**, a polymorphic ventricular tachycardia that can lead to recurrent syncope or sudden cardiac death [1], [2]. **2. Why other options are incorrect:** * **Brugada Syndrome:** Characterized by a pseudo-right bundle branch block (RBBB) and ST-segment elevation in leads V1-V3 (Coved type). It does not involve QT prolongation. * **Arrhythmogenic RV Dysplasia (ARVD):** Involves fibro-fatty replacement of the right ventricular myocardium. Key ECG findings include the **Epsilon wave** (small notch at the end of the QRS) and T-wave inversions in V1-V3. * **Lev’s Disease:** An acquired form of complete heart block due to idiopathic fibrosis and calcification of the electrical conduction system (sclerosis of the cardiac skeleton), typically seen in the elderly. **3. High-Yield Clinical Pearls for NEET-PG:** * **Congenital LQTS Types:** * **Romano-Ward Syndrome:** Autosomal Dominant (Pure cardiac phenotype). * **Jervell and Lange-Nielsen Syndrome:** Autosomal Recessive (Associated with **sensorineural deafness**). * **Triggers:** LQT1 is often triggered by exercise/swimming; LQT2 by auditory stimuli (alarm clocks); LQT3 occurs during sleep. * **Management:** Beta-blockers (Propranolol/Nadolol) are the first-line treatment; ICD is indicated for high-risk patients. Avoid QT-prolonging drugs (e.g., Macrolides, Ondansetron, Class IA/III antiarrhythmics).

Q: All of the following statements about chronic constrictive pericarditis are true except?

The commonest cause in India is 'Idiopathic'.. **Explanation:** The correct answer is **Option A**. In the context of India, **Tuberculosis** remains the most common cause of chronic constrictive pericarditis (CCP) [1]. While "Idiopathic" or post-viral causes are the leading etiology in developed nations, the high prevalence of TB in the Indian subcontinent makes it the primary driver of pericardial thickening and calcification [1]. **Analysis of other options:** * **Option B (Kussmaul’s Sign):** This is a classic finding in CCP. It refers to the paradoxical rise (or lack of fall) in Jugular Venous Pressure (JVP) during inspiration because the rigid pericardium prevents the right ventricle from expanding to accommodate increased venous return. * **Option C (Ascites vs. Edema):** In CCP, **Ascites precox** is often seen. Due to chronic high systemic venous pressure and hepatic congestion, ascites develops early and is often more prominent than peripheral edema. * **Option D (RV End-Diastolic Pressure):** In CCP, there is "equalization of diastolic pressures" in all four cardiac chambers. The rigid shell limits ventricular filling, leading to an elevation and plateauing of the RVEDP, LVEDP, and mean atrial pressures. **NEET-PG High-Yield Pearls:** * **Square Root Sign:** Also known as the "Dip and Plateau" pattern seen on pressure tracings of the ventricles. * **Pericardial Knock:** A high-pitched sound heard in early diastole due to the sudden cessation of ventricular filling. * **Chest X-ray:** May show pericardial calcification (best seen in lateral view). * **Treatment:** The definitive treatment is **Surgical Pericardiectomy** [1].

Q: Which of the following statements is NOT true regarding right-sided infective endocarditis?

Unlikely in the absence of a murmur. In Right-Sided Infective Endocarditis (RSIE), the correct answer is **Option A** because the statement "Unlikely in the absence of a murmur" is **false**. Unlike left-sided endocarditis, where murmurs are present in over 85% of cases, a murmur is frequently **absent** in RSIE (occurring in only about 35-50% of patients). This is because the pressure gradient across the tricuspid valve is lower than the mitral or aortic valves, making the resulting turbulence less audible. **Analysis of other options:** * **Option B:** IV drug use (IVDU) is the most common risk factor for RSIE, typically involving the tricuspid valve [1]. *Staphylococcus aureus* is the most frequent pathogen in this cohort [1]. * **Option C:** Since the vegetation is on the right side (tricuspid/pulmonary valves), fragments embolize via the pulmonary artery [1]. This leads to **septic pulmonary emboli**, causing cough, chest pain, and hemoptysis. Systemic emboli (to brain or spleen) are rare unless a right-to-left shunt (e.g., Patent Foramen Ovale) exists. * **Option D:** Septic abortion or pelvic infections can lead to RSIE via the pelvic venous plexus, which drains into the inferior vena cava and reaches the right heart. **High-Yield Clinical Pearls for NEET-PG:** * **Most common valve involved in IVDU:** Tricuspid Valve. * **Triad of RSIE:** Fever, anemia, and multiple patchy pulmonary infiltrates (septic emboli). * **Chest X-ray:** Often shows "flea-bitten" appearance or multiple peripheral cavitary lesions. * **Treatment:** Often requires longer courses of antibiotics; surgery is less common than in left-sided IE but indicated for large vegetations (>20mm) or persistent infection.

Q: Pericardial effusion is best diagnosed by?

Echocardiography. **Explanation:** **Echocardiography (Option B)** is the gold standard and investigation of choice for diagnosing pericardial effusion. It is highly sensitive, non-invasive, and can detect as little as **15–20 mL** of fluid. It allows for the visualization of an "echo-free space" between the epicardium and parietal pericardium. Crucially, it can assess hemodynamic significance, such as signs of cardiac tamponade (e.g., right ventricular diastolic collapse). **Why other options are incorrect:** * **Chest X-ray (Option A):** While a "Water-bottle" or "Money-bag" heart appearance is classic, it is non-specific and only becomes apparent when at least **200–250 mL** of fluid has accumulated. * **ECG (Option C):** May show low voltage QRS complexes or **Electrical Alternans** (pathognomonic for large effusions/tamponade), but these are late findings and lack the sensitivity required for a primary diagnosis. * **Angiography (Option D):** This is an invasive procedure used primarily for coronary anatomy or pressures; it is not used for diagnosing pericardial fluid. **High-Yield Clinical Pearls for NEET-PG:** * **Investigation of Choice:** Echocardiography. * **Most Sensitive Imaging:** MRI (can detect even smaller amounts and characterize fluid), but Echo remains the practical first-line gold standard. * **Swinging Heart Syndrome:** Seen on Echo in large effusions, leading to Electrical Alternans on ECG. * **Beck’s Triad (Tamponade):** Hypotension, JVD, and muffled heart sounds. * **Ewart’s Sign:** Dullness to percussion at the left lung base due to compression by a large pericardial sac.

Q: In left ventricular hypertrophy (LVH), what is the typical criteria for the sum of SV1 and RV6 in millimeters?

35 mm. ### Explanation **1. The Correct Answer: C (35 mm)** The question refers to the **Sokolow-Lyon Criteria**, one of the most widely used ECG tools for diagnosing Left Ventricular Hypertrophy (LVH). In LVH, the increased muscle mass of the left ventricle generates higher electrical voltages during depolarization. Because the left ventricle is posterior and to the left, these increased forces are directed away from the right-sided precordial leads (causing a deep **S wave in V1**) and toward the left-sided leads (causing a tall **R wave in V5 or V6**). * **Criteria:** SV1 + (RV5 or RV6) ≥ 35 mm (in adults >35 years). **2. Analysis of Incorrect Options:** * **Option A (25 mm) & B (30 mm):** These values are below the established threshold for the Sokolow-Lyon index. While a sum of 30 mm might be suggestive in older patients with thin chest walls, it lacks the specificity required for a formal diagnosis of LVH. * **Option D (45 mm):** This value is significantly higher than the standard diagnostic cutoff. While a sum of 45 mm is highly specific for LVH, using it as the "typical criteria" would result in many false negatives (low sensitivity). **3. Clinical Pearls for NEET-PG:** * **Cornell Criteria:** Another high-yield index. It is defined as **R in aVL + S in V3 > 28 mm (men)** or **> 20 mm (women)**. It is often considered more accurate than Sokolow-Lyon. * **Strain Pattern:** Look for asymmetrical ST-segment depression and T-wave inversion in lateral leads (V5, V6, I, aVL); this indicates chronic pressure overload. * **Romhilt-Estes Point System:** A scoring system where a score of ≥5 is definitive for LVH. * **Limitation:** ECG has high specificity but **low sensitivity** for LVH; Echocardiography remains the gold standard for assessing ventricular mass.

Q: A 61-year-old male presented to the OPD with complaints of dyspnea, chest pain, and syncope. What is he most likely suffering from?

Aortic Stenosis (AS). The classic triad of **Dyspnea, Angina (chest pain), and Syncope** is the hallmark clinical presentation of **Symptomatic Aortic Stenosis (AS)**. ### 1. Why Aortic Stenosis is Correct In AS, the narrowing of the aortic valve causes a fixed left ventricular outflow tract obstruction [1]. * **Angina:** Occurs due to increased myocardial oxygen demand (from LV hypertrophy) and decreased supply (due to high wall tension and compression of coronary arteries). * **Syncope:** Typically exertional, caused by the inability of the heart to increase cardiac output during exercise, leading to reduced cerebral perfusion, or due to the baroreceptor reflex causing vasodilation. * **Dyspnea:** Indicates the onset of heart failure as the left ventricle fails to pump against the high pressure, leading to pulmonary congestion [2]. ### 2. Why Other Options are Incorrect * **Mitral Stenosis (MS):** Primarily presents with dyspnea, hemoptysis, and palpitations (due to Atrial Fibrillation). Syncope and chest pain are rare. * **Mitral Regurgitation (MR):** Presents with chronic fatigue and exertional dyspnea [3]. It does not typically cause syncope unless associated with severe arrhythmias. * **Tricuspid Regurgitation (TR):** Presents with signs of right-sided heart failure, such as peripheral edema, hepatomegaly, and elevated JVP, rather than the classic AS triad. ### 3. High-Yield Clinical Pearls for NEET-PG * **The "SAD" Mnemonic:** **S**yncope, **A**ngina, **D**yspnea (in order of worsening prognosis). * **Average Survival:** Once symptoms appear, survival is roughly: Angina (5 years), Syncope (3 years), Dyspnea/HF (2 years). * **Physical Exam:** Look for **Pulsus Parvus et Tardus** (slow-rising, low-volume pulse) and a **harsh crescendo-decrescendo systolic murmur** radiating to the carotids [1]. * **Management:** Symptomatic severe AS is an absolute indication for **Aortic Valve Replacement (AVR/TAVI)** [2].

Q: A young female presents with a history of dyspnea on exertion. On examination, she has a wide, fixed split S2 with an ejection systolic murmur in the left second intercostal space. Her ECG shows left axis deviation. What is the most probable diagnosis?

Ostium primum atrial septal defect. ### Explanation The clinical presentation of a **wide, fixed split S2** and an **ejection systolic murmur (ESM)** in the left second intercostal space is classic for an **Atrial Septal Defect (ASD)**. The ESM is caused by increased stroke volume across the pulmonary valve, not the defect itself. The differentiating factor in this question is the **ECG finding of Left Axis Deviation (LAD)**. * **Ostium Secundum ASD** (the most common type) typically presents with **Right Axis Deviation (RAD)** and RSR' pattern (RBBB). * **Ostium Primum ASD** (part of the endocardial cushion defects) is uniquely associated with **Left Axis Deviation** due to the postero-inferior displacement of the AV node and the early activation of the left ventricle. #### Why the other options are incorrect: * **Total Anomalous Pulmonary Venous Drainage (TAPVD):** While it presents with a wide, fixed split S2, the ECG typically shows severe Right Ventricular Hypertrophy (RVH) and **Right Axis Deviation**, not LAD. * **Tricuspid Atresia:** This condition does present with LAD and a cyanotic picture, but it would not feature a wide, fixed split S2 or the characteristic ESM of an ASD. * **VSD with PAH (Eisenmenger Syndrome):** A VSD typically presents with a pansystolic murmur. Once PAH develops, the murmur may disappear and S2 becomes loud and single (or narrowly split), not wide and fixed. #### NEET-PG High-Yield Pearls: * **ASD + LAD = Ostium Primum ASD** (associated with Down Syndrome). * **ASD + RAD = Ostium Secundum ASD** (most common type). * **Fixed splitting of S2** occurs because the respiratory variations in venous return are buffered by the large atrial shunt, keeping the stroke volume of the right ventricle constant throughout the respiratory cycle. * **Lutembacher Syndrome:** Mitral stenosis + Ostium secundum ASD.

Q: Which of the following is NOT a typical ECG feature of primary pulmonary hypertension?

ST elevation. Primary Pulmonary Hypertension (PPH) leads to chronic pressure overload of the right side of the heart, resulting in **Right Ventricular Hypertrophy (RVH)** and **Right Atrial Enlargement (RAE)** [1, 3]. **Why ST Elevation is the correct answer:** ST elevation is typically a marker of acute myocardial infarction or pericarditis [3]. In the context of pulmonary hypertension, the ECG usually shows signs of right heart strain, which manifests as **ST-segment depression** and **T-wave inversion** in the right precordial leads (V1–V3), rather than ST elevation [1, 3]. **Analysis of incorrect options:** * **Sinus Tachycardia:** This is a common, non-specific finding in pulmonary hypertension as the heart attempts to maintain cardiac output despite increased pulmonary vascular resistance [1]. * **Increased P wave amplitude:** Known as **P-pulmonale**, this refers to a peaked P wave >2.5 mm in lead II. it is a classic sign of right atrial enlargement due to high pulmonary pressures [2]. * **Right Axis Deviation (RAD):** As the right ventricle hypertrophies, the mean electrical axis shifts toward the right (usually >+90°), making this a hallmark feature of the condition [1, 3]. **High-Yield Clinical Pearls for NEET-PG:** * **ECG Triad of RVH:** Right Axis Deviation, dominant R wave in V1 (>7mm), and right ventricular strain pattern (ST depression/T wave inversion in V1-V3) [1, 3]. * **S1Q3T3:** While classic for Pulmonary Embolism (acute cor pulmonale), it is less common in chronic primary pulmonary hypertension [1]. * **Gold Standard Diagnosis:** Right heart catheterization (Mean Pulmonary Artery Pressure >20 mmHg at rest).

Question 1

In a patient with a history of recurrent syncope, a Holter recording shows a QT interval of 680 msec. Which disease is suspected in this patient?

Accepted Answer

Long QT syndrome

Answer

Brugada syndrome

Answer

Arrhythmogenic RV dysplasia

Answer

Lev's disease

Question 2

All of the following statements about chronic constrictive pericarditis are true except?

Accepted Answer

The commonest cause in India is 'Idiopathic'.

Answer

Kussmaul's sign is present.

Answer

Ascites is not in proportion to edema.

Answer

Right ventricular end-diastolic pressure is raised.

Question 3

Resistant hypertension is defined as?

Accepted Answer

Hypertension resistant to 3 or more antihypertensive drugs, including a thiazide diuretic

Answer

Hypertension resistant to 3 or more antihypertensive drugs

Answer

Hypertension resistant to aldosterone

Answer

Hypertension with resistance of Angiotensin II receptors

Question 4

Which of the following statements is NOT true regarding right-sided infective endocarditis?

Accepted Answer

Unlikely in the absence of a murmur

Answer

It is commonly seen in intravenous drug users

Answer

Emboli to organs other than the lung are rare

Answer

Can occur following septic abortion

Question 5

Pericardial effusion is best diagnosed by?

Accepted Answer

Echocardiography

Answer

Chest X-ray

Answer

ECG

Answer

Angiography

Question 6

What is/are the positive ECG sign(s) of ischemia in a treadmill test?

Accepted Answer

Downsloping depression of the ST segment >0.1 mm below baseline

Answer

Upsloping depression of the ST segment 1 mm below baseline

Answer

Junctional ST-segment changes

Answer

Tachycardia

Question 7

In left ventricular hypertrophy (LVH), what is the typical criteria for the sum of SV1 and RV6 in millimeters?

Accepted Answer

35 mm

Answer

25 mm

Answer

30 mm

Answer

45 mm

Question 8

A 61-year-old male presented to the OPD with complaints of dyspnea, chest pain, and syncope. What is he most likely suffering from?

Accepted Answer

Aortic Stenosis (AS)

Answer

Mitral Stenosis (MS)

Answer

Mitral Regurgitation (MR)

Answer

Tricuspid Regurgitation (TR)

Question 9

A young female presents with a history of dyspnea on exertion. On examination, she has a wide, fixed split S2 with an ejection systolic murmur in the left second intercostal space. Her ECG shows left axis deviation. What is the most probable diagnosis?

Accepted Answer

Ostium primum atrial septal defect

Answer

Total anomalous pulmonary venous drainage

Answer

Tricuspid atresia

Answer

Ventricular septal defect with pulmonary arterial hypertension

Question 10

Which of the following is NOT a typical ECG feature of primary pulmonary hypertension?

Accepted Answer

ST elevation

Answer

Sinus tachycardia

Answer

Increased P wave amplitude

Answer

Right axis deviation

Cardiology — MCQs

Cardiology — MCQs

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