Cardiology Practice Questions

Q: A female patient complains of chest pain while waking up in the morning. Pain is more in winter months. Which of the following best describes this patient?

Ach-induced coronary vasoconstriction. ***Ach-induced coronary vasoconstriction***- This clinical presentation—chest pain at rest (especially in the morning hours) and exacerbation during winter months (due to cold exposure)—is the hallmark of **Variant (Prinzmetal's) angina**, which is caused by transient **coronary vasospasm**. [1]- The mechanism involves underlying endothelial dysfunction leading to hyperreactivity of coronary smooth muscle, which can be demonstrated via provoked spasm using agents like **Acetylcholine (ACh)** during diagnostic tests. [1]*Fixed plaque obstruction*- This pathology defines **Stable Angina**, where chest pain is typically predictable and primarily brought on by physical **exertion** when myocardial oxygen demand exceeds fixed supply. [1]- Stable angina rarely occurs exclusively at rest upon waking and does not typically exhibit marked seasonal variation associated with **vasospasm** triggers like cold.*Subendocardial ischemia due to increased demand of myocardium*- Demand ischemia results from factors that increase myocardial workload (e.g., high heart rate, exercise), leading to supply-demand mismatch, which is minimized during rest/sleep. [1]- Prinzmetal's angina is a *supply* problem (vasospasm) causing acute, severe **transmural ischemia**, often presenting with transient **ST elevation** on ECG, differentiating it from typical subendocardial demand ischemia.*Increased sympathomimetic drive in morning hours*- While the natural circadian rhythm involves an increase in sympathetic tone upon waking, potentially triggering cardiac events, this does not describe the specific mechanism of the chest pain.- The symptoms described are most diagnostic of **Prinzmetal's angina**, a distinct disorder defined by localized arterial hyperreactivity rather than general sympathetic increase.

Q: A patient after MI develops a broad QRS complex tachycardia. His BP is 120/85 mm Hg. ECG is given below. Best management?

Amiodarone iv. ***Amiodarone iv*** - The ECG shows a **monomorphic wide-complex tachycardia** in a patient with a history of myocardial infarction, which is presumed to be **ventricular tachycardia (VT)** until proven otherwise. - For a **hemodynamically stable** patient (BP 120/85 mm Hg), intravenous antiarrhythmics like **amiodarone** or procainamide are the first-line treatment for terminating the arrhythmia. *Labetalol iv* - Intravenous beta-blockers like labetalol are generally avoided in the acute management of VT, especially in patients with structural heart disease. - Their **negative inotropic** effects can precipitate **hemodynamic collapse** and cardiogenic shock in a heart already compromised by a recent MI. *Metoprolol iv* - Similar to labetalol, metoprolol is a beta-blocker that is not recommended for the acute termination of VT. - While crucial for long-term management post-MI, its administration during an active VT episode can lead to severe **hypotension** and cardiac decompensation. *Nitroglycerin iv* - Nitroglycerin is a vasodilator used for ischemic chest pain and has no **antiarrhythmic properties** to terminate VT. - Its use could cause significant **vasodilation** and hypotension, potentially destabilizing the patient and converting a stable VT into an unstable one requiring immediate cardioversion.

Q: A patient presents to the ER with central chest pain. He has a past medical history of heart disease. ECG is shown below. What is the diagnosis?

Anterolateral MI. ***Anterolateral MI*** - The ECG shows significant **ST-segment elevation** in the anterior leads (**V1-V4**) and the lateral leads (**I, aVL, V5, V6**), which is characteristic of an extensive anterolateral myocardial infarction. - This pattern typically indicates an occlusion of the proximal **Left Anterior Descending (LAD) artery**. The ST depression in the inferior leads (II, III, aVF) represents **reciprocal changes**. *Inferolateral MI* - An inferolateral MI would present with ST elevation in the **inferior leads (II, III, aVF)** and lateral leads (I, aVL, V5, V6). - This ECG shows **ST depression** in the inferior leads, which argues against an inferior wall infarction and instead supports an anterior MI as reciprocal changes. *Acute pericarditis* - Acute pericarditis typically causes **diffuse, concave ST elevation** across multiple territories, not localized to the anterolateral leads as seen here. - It is also often associated with **PR segment depression**, which is not a prominent feature in this ECG. The ST segments here are **convex (coved)**, which is more typical for MI. *Constrictive pericarditis* - This is a chronic condition and does not cause acute ST-segment elevation. Its ECG findings are usually non-specific. - Typical findings for constrictive pericarditis include **low-voltage QRS complexes** and generalized T-wave flattening or inversion, which are not present on this ECG.

Q: A patient with a history of rheumatic fever presents with a loud S1 and a low-pitched mid-diastolic murmur at the apex (best heard with the patient in the left lateral position). What is the most likely diagnosis?

Mitral Stenosis (MS). ***Mitral Stenosis (MS)*** - The classic auscultatory findings include a **loud S1** (due to forceful closure of the stiff mitral valve) and a low-pitched, rumbling **mid-diastolic murmur** at the apex, which are pathognomonic for MS [3]. - A history of **rheumatic fever** is the most common cause of mitral stenosis worldwide. The murmur is best heard in the **left lateral decubitus position**, and an **opening snap (OS)** may be heard after S2 [1], [3]. *Tricuspid Stenosis (TS)* - TS produces a mid-diastolic murmur, but it is best heard at the **left lower sternal border**, not the apex [2]. - The murmur of TS characteristically **intensifies with inspiration** (Carvallo's sign), a feature not described in this patient. *Mitral Regurgitation (MR)* - MR causes a **holosystolic (pansystolic) murmur**, meaning it occurs throughout systole, not diastole. - In chronic MR, the S1 sound is typically **soft or absent**, not loud, due to incomplete closure of the mitral valve leaflets. *Aortic Regurgitation (AR)* - AR is characterized by a high-pitched, blowing, **early diastolic decrescendo murmur** best heard along the left sternal border [4]. - It is associated with signs of a wide pulse pressure, such as **bounding peripheral pulses** (Corrigan's pulse), not a loud S1 or a mid-diastolic murmur at the apex.

Q: A 25-year-old female with a previous history of rheumatic fever. Examination shows a loud S1 and mid-diastolic murmur. Which of the following valvular heart diseases does she have?

MS. ***MS*** - The combination of a history of **rheumatic fever** (the most common cause of MS globally) and the specific auscultatory findings are highly diagnostic of **mitral stenosis** [1]. - A **loud S1** results from the abrupt closure of the stiffened, high-pressure mitral valve, and a **mid-diastolic murmur** is caused by turbulent flow across the stenotic valve during rapid ventricular filling [2], [3]. *TS* - Tricuspid Stenosis (TS) is a rare sequelae of rheumatic fever and typically presents with a mid-diastolic murmur that *increases* with **inspiration** (**Carvallo's sign**) [2]. - The murmur of TS is best heard at the **left sternal border** (tricuspid area) and is usually accompanied by prominent signs of systemic congestion (e.g., ascites). *MR* - **Mitral Regurgitation** produces a high-pitched, blowing **holosystolic murmur** that typically radiates to the axilla, not a mid-diastolic murmur. - A loud S1 is often *absent* in significant MR as the valve leaflets do not coapt properly; S1 is usually normal or soft. *AR* - **Aortic Regurgitation** is characterized by a high-pitched **diastolic decrescendo murmur** best heard along the left sternal border [4]. - AR is frequently associated with signs of increased stroke volume and wide pulse pressure, such as the **Water-hammer pulse**, none of which are characteristic of this presentation.

Q: An alcoholic patient presents with palpitations, dizziness, and syncopal attacks. On examination, irregularly irregular pulse is seen. What will be seen on JVP?

Absent a wave. ***Absent a wave*** - The clinical presentation of an alcoholic with palpitations and an **irregularly irregular pulse** is highly suggestive of **Atrial Fibrillation (AFib)** [1]. - The **'a' wave** in the Jugular Venous Pressure (JVP) corresponds to **atrial contraction**. In AFib, coordinated atrial contraction is lost, leading to the absence of the 'a' wave. *Large a wave* - A large or "giant" 'a' wave indicates that the right atrium is contracting against an increased resistance, forcing it to generate higher pressure. - This is classically seen in conditions such as **tricuspid stenosis**, **pulmonary stenosis**, and severe **pulmonary hypertension**. *Canon a wave* - Cannon 'a' waves are intermittent, very large 'a' waves that occur when the atria contract against a **closed tricuspid valve**. - This finding is characteristic of **AV dissociation**, which can be seen in **complete heart block**, ventricular tachycardia, or junctional rhythms. *Steep y descent* - A steep 'y' descent, also known as **Friedreich's sign**, reflects rapid, unimpeded filling of the right ventricle from the right atrium. - It is a classic sign of **constrictive pericarditis** and can also be present in severe **right-sided heart failure** or **tricuspid regurgitation**.

Q: A 68-year-old male patient with a history of hypertension presents to the emergency department in acute distress. He is diaphoretic, tachycardic, and complains of severe chest pain. His vital signs show a heart rate of 180 bpm with a regular, wide-complex tachycardia consistent with ventricular tachycardia. The patient appears hemodynamically unstable. What is the most appropriate immediate management for this patient?

Synchronized cardioversion. Detailed Analysis of Ventricular Tachycardia Management: ***Synchronized cardioversion*** - The ECG shows a regular, wide-complex tachycardia, consistent with **ventricular tachycardia (VT)**. The patient's clinical presentation with severe chest pain and diaphoresis indicates **hemodynamic instability** [1]. - For any unstable tachyarrhythmia, including VT, immediate **synchronized electrical cardioversion** is the first-line treatment to restore sinus rhythm and prevent cardiovascular collapse [2]. *Amiodarone* - Amiodarone is an antiarrhythmic medication that is appropriate for **stable ventricular tachycardia**, where the patient has adequate blood pressure and is not in acute distress. - In an unstable patient, electrical cardioversion should not be delayed for a trial of pharmacologic therapy, as this can lead to further deterioration [2]. *Radiofrequency catheter ablation* - This is an elective, invasive procedure used for the long-term prevention of recurrent arrhythmias, not for the acute management of an unstable patient. - Catheter ablation is typically considered after the patient has been stabilized and if they experience recurrent episodes of VT. *Digoxin* - Digoxin is primarily used for rate control in supraventricular tachycardias like **atrial fibrillation** and is not effective for treating ventricular tachycardia [3]. - Administering digoxin in this setting is inappropriate and can potentially worsen the arrhythmia or cause toxicity [3].

Q: A 72 y/o woman presents with severe chest pain and shortness of breath after a stressful argument. She is post-menopausal with no history of heart disease. O/E, she is slightly tachycardic with normal blood pressure. An echocardiogram shows left ventricular ballooning during systole, and cardiac enzymes are minimally elevated. What is the most likely diagnosis?

Takotsubo Cardiomyopathy. ***Takotsubo Cardiomyopathy*** - **Stress-induced cardiomyopathy** (broken heart syndrome) typically affects **post-menopausal women** following emotional or physical stress [2]. - Classic presentation: **chest pain mimicking acute MI** with **minimal cardiac enzyme elevation** (troponin may be mildly elevated but disproportionately low for the degree of wall motion abnormality) - **Pathognomonic finding**: **Apical ballooning** (or mid-ventricular ballooning) on echocardiography during systole, with **hyperkinetic basal segments** creating characteristic "octopus trap" appearance - Usually **reversible** within weeks to months with supportive care - Coronary angiography shows **normal or non-obstructive coronary arteries** *Incorrect: Coronary Artery Disease* - Would show **significantly elevated cardiac enzymes** (troponin, CK-MB) proportionate to myocardial damage [1]. - Echo would show wall motion abnormalities in **coronary artery distribution** (not apical ballooning pattern) - Risk factors and chronic history more common [3]. *Incorrect: Pulmonary Embolism* - Would present with **right ventricular strain** on echo, not left ventricular ballooning - Different chest pain character (pleuritic), associated with **hypoxemia** and **tachypnea** - D-dimer elevated, cardiac enzymes usually normal unless massive PE *Incorrect: Hypertensive Heart Disease* - Patient has **normal blood pressure** on examination - Would show **left ventricular hypertrophy** and diastolic dysfunction, not acute ballooning - Chronic presentation, not acute stress-related event

Q: A patient with a history of throat infection presents with a water hammer pulse. What is the most likely diagnosis?

Rheumatic fever with aortic regurgitation. ***Rheumatic fever with aortic regurgitation***- The history of a preceding **streptococcal throat infection** suggests **Acute Rheumatic Fever (ARF)**, which is the leading cause of acquired valvular heart disease globally.- **Aortic Regurgitation (AR)** is a common manifestation of rheumatic carditis [1] and characteristically presents with physical signs of high pulse pressure, such as the bounding, rapidly collapsing pulse known as the **water hammer pulse** (Corrigan's pulse) [2].*Infective endocarditis*- Although **infective endocarditis (IE)** can cause acute **Aortic Regurgitation (AR)** due to cusp destruction [3], the history of a preceding **throat infection** is a classic antecedent for **rheumatic fever**, not typical IE.- IE usually presents with fever, new murmur, and systemic emboli, often in patients with pre-existing valve disease or intravenous drug use.*Mitral stenosis*- **Mitral stenosis (MS)** results in decreased flow from the left atrium to the left ventricle, which *does not* lead to wide pulse pressure.- It is characterized by a **loud S1**, **opening snap**, and **mid-diastolic rumble**; MS does not cause a water hammer pulse, which is specific to **Aortic Regurgitation**.*Aortic stenosis*- **Aortic stenosis (AS)** causes mechanical obstruction to left ventricular outflow, resulting in low pulse pressure and a small, slow-rising pulse (**pulsus parvus et tardus**) [4].- AS is hemodynamically the opposite of **Aortic Regurgitation**, and therefore highly unlikely to present with a wide pulse pressure or a **water hammer pulse**.

Question 1

A female patient complains of chest pain while waking up in the morning. Pain is more in winter months. Which of the following best describes this patient?

Accepted Answer

Ach-induced coronary vasoconstriction

Answer

Fixed plaque obstruction

Answer

Increased sympathomimetic drive in morning hours

Answer

Subendocardial ischemia due to increased demand of myocardium

Question 2

A patient after MI develops a broad QRS complex tachycardia. His BP is 120/85 mm Hg. ECG is given below. Best management?

Accepted Answer

Amiodarone iv

Answer

Nitroglycerin iv

Answer

Metoprolol iv

Answer

Labetalol iv

Question 3

A patient presents to the ER with central chest pain. He has a past medical history of heart disease. ECG is shown below. What is the diagnosis?

Accepted Answer

Anterolateral MI

Answer

Inferolateral MI

Answer

Constrictive pericarditis

Answer

Acute pericarditis

Question 4

A patient with a history of rheumatic fever presents with a loud S1 and a low-pitched mid-diastolic murmur at the apex (best heard with the patient in the left lateral position). What is the most likely diagnosis?

Accepted Answer

Mitral Stenosis (MS)

Answer

Tricuspid Stenosis (TS)

Answer

Mitral Regurgitation (MR)

Answer

Aortic Regurgitation (AR)

Question 5

A 25-year-old female with a previous history of rheumatic fever. Examination shows a loud S1 and mid-diastolic murmur. Which of the following valvular heart diseases does she have?

Accepted Answer

MS

Answer

TS

Answer

MR

Answer

AR

Question 6

An alcoholic patient presents with palpitations, dizziness, and syncopal attacks. On examination, irregularly irregular pulse is seen. What will be seen on JVP?

Accepted Answer

Absent a wave

Answer

Steep y descent

Answer

Large a wave

Answer

Canon a wave

Question 7

A 68-year-old male patient with a history of hypertension presents to the emergency department in acute distress. He is diaphoretic, tachycardic, and complains of severe chest pain. His vital signs show a heart rate of 180 bpm with a regular, wide-complex tachycardia consistent with ventricular tachycardia. The patient appears hemodynamically unstable. What is the most appropriate immediate management for this patient?

Accepted Answer

Synchronized cardioversion

Answer

Amiodarone

Answer

Radiofrequency catheter ablation

Answer

Digoxin

Question 8

A 72 y/o woman presents with severe chest pain and shortness of breath after a stressful argument. She is post-menopausal with no history of heart disease. O/E, she is slightly tachycardic with normal blood pressure. An echocardiogram shows left ventricular ballooning during systole, and cardiac enzymes are minimally elevated. What is the most likely diagnosis?

Accepted Answer

Takotsubo Cardiomyopathy

Answer

Pulmonary Embolism

Answer

Coronary Artery Disease

Answer

Hypertensive Heart Disease

Question 9

A 65-year-old male with chronic stable angina presents with worsening chest pain during routine activities. His current medications include aspirin, clopidogrel, metoprolol, and atorvastatin, but his symptoms persist. ECG shows ST-segment depression in V5-V6, and coronary angiography reveals 80% stenosis of the left anterior descending (LAD) artery. What is the most appropriate intervention?

Accepted Answer

Percutaneous coronary intervention (PCI) with drug-eluting stent (DES)

Answer

Add ranolazine to medical therapy

Answer

Increase the dose of beta-blockers

Answer

Refer for coronary artery bypass grafting (CABG)

Question 10

A patient with a history of throat infection presents with a water hammer pulse. What is the most likely diagnosis?

Accepted Answer

Rheumatic fever with aortic regurgitation

Answer

Infective endocarditis

Answer

Aortic stenosis

Answer

Mitral stenosis

Cardiology — MCQs

Cardiology — MCQs

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