Cardiology Practice Questions

Q: This ECG was recorded from a 60 -year-old woman with hypertension. Which is correct about the ECG shown?

Left ventricular hypertrophy. ***Left ventricular hypertrophy*** - The ECG shows significantly **increased R wave amplitude** in lead V5 (approximately 30 small boxes or 30mm) and V6 (approximately 22 small boxes), along with deep S waves in V1 (approximately 18 small boxes), satisfying various voltage criteria for LVH, such as the **Sokolow-Lyon index** (SV1 + RV5 or RV6 ≥ 35mm; here SV1 + RV5 = 18 + 30 = 48mm). - The ST depression with asymmetric T-wave inversion in V5 and V6 are also consistent with **repolarization abnormalities** (lateral LVH strain pattern) often seen in LVH. *Left axis deviation* - The QRS complex is predominantly positive in lead I and negative in lead aVF, suggesting a leftward axis. However, the QRS complex remains **positive in lead II**, indicating a normal leftward axis rather than true left axis deviation. - For left axis deviation, the QRS complex should be **negative in lead II and aVF**, which is not the case here. *Atrial fibrillation* - The ECG shows clear, regular P waves followed by QRS complexes, indicating a **regular rhythm with discernible P waves**, inconsistent with atrial fibrillation which is characterized by an irregularly irregular rhythm and absence of P waves. - The **RR intervals are regular**, ruling out the chaotic rhythm of atrial fibrillation. *Aortic dissection* - Aortic dissection is a clinical diagnosis and while it can cause ECG changes due to myocardial ischemia or infarction (if coronary arteries are involved), there are **no specific ECG changes** that diagnose aortic dissection directly. - The ECG findings here directly point to **cardiac structural changes** (LVH) rather than an acute vascular emergency like aortic dissection.

Q: This ECG is of a 23 -year-old medical student who complained of an irregular heartbeat. Other than an irregular pulse, his heart was clinically normal. What does the ECG show?

Ventricular extrasystole. ***Ventricular extrasystole*** - The ECG shows occasional **premature, wide QRS complexes** not preceded by a P wave, originating from the ventricles. These are classic signs of ventricular extrasystoles (also known as premature ventricular contractions or PVCs). - The **irregular heartbeat** complained of by the patient is consistent with the presence of these extra beats, which disrupt the normal rhythm. *Sinus tachycardia* - Sinus tachycardia is characterized by a **regular heart rhythm** with a **heart rate above 100 bpm**, originating from the sinus node. - This ECG clearly shows an **irregular rhythm** and wide QRS complexes, which are not features of sinus tachycardia. *PSVT* - Paroxysmal supraventricular tachycardia (PSVT) typically presents as a **fast, regular rhythm** with **narrow QRS complexes** and a sudden onset and termination. - The ECG in question exhibits **wide QRS complexes** and an **irregular rhythm**, making PSVT an unlikely diagnosis. *Complete heart block* - Complete heart block is characterized by a **dissociation between atrial and ventricular activity**, where P waves and QRS complexes are dissociated despite usually regular atrial and ventricular rhythms occurring independently of each other. - The presence of **normal QRS complexes interspersed with wide, premature beats** is not consistent with the fixed AV dissociation seen in complete heart block.

Q: Which is correct about the ECG shown below?

Atrial flutter 4:1 conduction. ***Atrial flutter 4:1 conduction*** - The ECG shows regular **sawtooth flutter waves** in leads II, III, and aVF, characteristic of atrial flutter. - There are four flutter waves for every QRS complex, indicating a **4:1 conduction ratio** from the atria to the ventricles. *P pulmonale* - **P pulmonale** is characterized by tall, peaked P waves (amplitude >2.5 mm) in leads II, III, or aVF, indicative of **right atrial enlargement**. - While there are P-like waves, they are **sawtooth patterns** consistent with flutter waves, not normal P waves with increased amplitude. *Electrical alternans* - **Electrical alternans** is a beat-to-beat variation in the **QRS complex amplitude** or axis, typically associated with large pericardial effusions. - The ECG shows consistent QRS complex morphology and amplitude, ruling out electrical alternans. *Atrial flutter 1:1 conduction* - In **atrial flutter with 1:1 conduction**, the ventricular rate would be extremely fast (around 300 bpm), often leading to **hemodynamic instability**. - The ventricular rate in this ECG is slower (approximately 75 bpm), inconsistent with 1:1 conduction.

Q: A 25-year-old girl presents with history of recurrent syncopal attacks. An ECG is obtained and shows a regular narrow-complex tachycardia at approximately 150 bpm with no clearly identifiable P waves distinct from the QRS complexes and no sawtooth flutter waves. Which is correct about the recording?

PSVT. ***PSVT*** - The ECG shows a **narrow QRS complex tachycardia with a regular rhythm** and a heart rate around 150 bpm, which is characteristic of Paroxysmal Supraventricular Tachycardia (PSVT). - In PSVT, **P waves are often hidden within the QRS complex** or T wave, or appear shortly after the QRS, as can be inferred from the rapid rate and regular narrow complex. - The absence of identifiable sawtooth flutter waves and the lack of distinct P waves separate from the QRS support PSVT (e.g., AVNRT or AVRT) as the most likely diagnosis. *Atrial flutter with 2:1 conduction (differential)* - Atrial flutter with 2:1 conduction can also present as a regular narrow-complex tachycardia near 150 bpm and must be considered in the differential. - However, atrial flutter typically shows **sawtooth flutter waves** (best seen in leads II, III, aVF, and V1), which are not present on this ECG. *P pulmonale* - **P pulmonale** is characterized by tall, peaked P waves (> 2.5 mm in height in inferior leads) and is indicative of **right atrial enlargement**. - The ECG does not show such P wave morphology; instead, the rapid rate makes P waves difficult to discern. *P mitrale* - **P mitrale** is characterized by wide, notched P waves (> 0.12 s in duration) and is indicative of **left atrial enlargement**. - This ECG pattern is inconsistent with P mitrale, as the P waves are either obscured or not widened/notched. *Electromechanical dissociation* - **Electromechanical dissociation (EMD)**, also known as pulseless electrical activity (PEA), occurs when there is organized electrical activity on the ECG but **no palpable pulse**. - EMD typically presents with a slow, wide QRS complex rhythm or a normal-looking rhythm without a mechanical response, which is not what is seen here; this ECG shows a fast, regular rhythm.

Q: A 30-year-old male was brought to the ER after a car crash. On admission, pulse is weak with BP=80 / 60 mm Hg. ECG is shown below. Right heart catheter is placed. Which is the most consistent value with patient's diagnosis?

16 | 34 / 16 | 16. ***16 | 34 / 16 | 16*** - The ECG shows low voltage QRS complexes and electrical alternans (alternating amplitude of P, QRS, and T waves), which are classic signs of **cardiac tamponade** due to fluid accumulation compromising cardiac filling. - In cardiac tamponade, there is an equalization of diastolic pressures in all four heart chambers, specifically the **right atrial (RA) pressure**, **right ventricular (RV) end-diastolic pressure**, and **pulmonary artery wedge pressure (PAWP)**, reflecting the extrinsic compression on the heart. *16 | 100 / 30 | 28* - This set of numbers (RA | RV | PAWP) shows a **significantly elevated RV systolic pressure (100 mmHg)**, which is indicative of **severe pulmonary hypertension** or right ventricular outflow tract obstruction, neither of which are consistent with tamponade. - While PAWP (28 mmHg) is elevated, the disparity between RV systolic pressure and RA pressure (16 mmHg) does not suggest the pressure equalization typical of tamponade. *16 | 45 / 22 | 20* - This data indicates an elevated RV systolic pressure (45 mmHg) and elevated RV end-diastolic pressure (22 mmHg), suggesting **right ventricular dysfunction** or pulmonary hypertension. - However, the PAWP (20 mmHg) is not significantly elevated to the point of equalizing with the RV end-diastolic pressure or RA pressure, which would signify cardiac tamponade. *16 | 75 / 30 | 11* - This option presents an **elevated RV systolic pressure (75 mmHg)** and an elevated RV end-diastolic pressure (30 mmHg), suggesting significant **right ventricular pressure overload**, likely due to severe pulmonary hypertension or a massive pulmonary embolism. - The **PAWP (11 mmHg)** is relatively low compared to the right-sided pressures, which rules out cardiac tamponade and suggests a problem primarily affecting the right heart and pulmonary circulation.

Q: The murmur of mitral regurgitation is best heard at

Cardiac apex. ***Cardiac apex*** - The **mitral valve** is located at the cardiac apex, and the murmur of **mitral regurgitation** is typically loudest at this point [1]. - Mitral regurgitation creates a **holosystolic murmur** that radiates to the axilla [1]. *Tricuspid area* - This area is located at the **lower left sternal border** and is where murmurs originating from the **tricuspid valve** are best heard, such as tricuspid regurgitation [2]. - Murmurs heard here are not characteristic of mitral valve dysfunction. *Aortic area* - The aortic area is at the **right upper sternal border**, primarily for auscultation of the **aortic valve**. - Conditions like **aortic stenosis** or **aortic regurgitation** are best heard here [3]. *Pulmonary area* - This area is located at the **left upper sternal border** and is where murmurs related to the **pulmonic valve** are best heard. - Examples include **pulmonic stenosis** or **pulmonic regurgitation**.

Q: Which one of the following is correct with regard to Carey Coombs murmur?

Soft mid-diastolic murmur due to mitral valvulitis. ***Soft mid-diastolic murmur due to mitral valvulitis*** - The **Carey Coombs murmur** is a soft, mid-diastolic murmur heard in acute rheumatic fever, characterized by inflammation of the mitral valve (mitral valvulitis) [4]. - It is distinct from the Austin Flint murmur and indicates active **rheumatic carditis** [4]. *Harsh early diastolic murmur due to aortic regurgitation* - An early diastolic murmur, especially a harsh one, typically indicates **aortic regurgitation**, which is a different valvular pathology [3]. - The Carey Coombs murmur is described as soft and mid-diastolic, not harsh and early diastolic. *Soft systolic murmur due to mitral regurgitation* - A soft systolic murmur suggests **mitral regurgitation**, which is a backflow of blood during systole [2]. - The Carey Coombs murmur is specifically a diastolic murmur, differentiating it from systolic murmurs [3]. *Blowing late systolic murmur due to aortic stenosis* - A blowing late systolic murmur is characteristic of **aortic stenosis**, where there is narrowing of the aortic valve. - The Carey Coombs murmur is an early to mid-diastolic murmur, related to mitral valve inflammation, not aortic stenosis [1].

Q: Consider the following statements for diagnosing ventricular aneurysm in a patient with recent myocardial infarction : I. Paradoxical impulse on chest wall II. Persistent ST elevation on ECG III. Unusual bulge from cardiac silhouette on X-ray IV. Presence of pulsus paradoxsus Which of the above are correct?

I, II and III. ***I, II and III*** - A **paradoxical impulse** on the chest wall (statement I) is a classic physical finding, indicating dyskinetic movement of the aneurysm during systole [1]. - **Persistent ST segment elevation** on ECG weeks to months after a myocardial infarction (statement II) is a hallmark sign, often reflecting the fibrous scar tissue of the aneurysm [1]. - An **unusual bulge** from the cardiac silhouette on X-ray (statement III) can indicate an enlarged left ventricular contour due to the aneurysm [1]. *II, III and IV* - While statements II and III are correct for diagnosing ventricular aneurysm, **pulsus paradoxus** (statement IV) is typically associated with **cardiac tamponade** or severe asthma/COPD, not directly with ventricular aneurysms. *I and II only* - Statements I and II are indeed correct indicators, but statement III, the **cardiac silhouette bulge on X-ray**, is also a valid and often observed finding for ventricular aneurysm [1]. *I and IV* - Statement I is correct, but **pulsus paradoxus** (statement IV) is not a diagnostic feature of ventricular aneurysm; it suggests conditions like **pericardial effusion** with tamponade.

Question 1

This ECG was recorded from a 60 -year-old woman with hypertension. Which is correct about the ECG shown?

Accepted Answer

Left ventricular hypertrophy

Answer

Left axis deviation

Answer

Atrial fibrillation

Answer

Aortic dissection

Question 2

This ECG is of a 23 -year-old medical student who complained of an irregular heartbeat. Other than an irregular pulse, his heart was clinically normal. What does the ECG show?

Accepted Answer

Ventricular extrasystole

Answer

Complete heart block

Answer

PSVT

Answer

Sinus tachycardia

Question 3

A patient presents with episodic rest chest pain due to coronary vasospasm (Prinzmetal's angina). Which of the following ECG findings will be seen during active vasospastic chest pain?

Accepted Answer

Transient ST-segment elevation with prominent peaked T-waves (Prinzmetal's vasospastic angina pattern)

Answer

Normal sinus rhythm with normal P-waves, QRS complexes, and T-waves

Answer

Widened QRS complex with ST-segment elevation bowed upward (left bundle branch block pattern)

Answer

Rapid, chaotic rhythm with no discernible P-waves (ventricular fibrillation)

Question 4

Which is correct about the ECG shown below?

Accepted Answer

Atrial flutter 4:1 conduction

Answer

P pulmonale

Answer

Electrical alternans

Answer

Atrial flutter 1:1 conduction

Question 5

A 25-year-old girl presents with history of recurrent syncopal attacks. An ECG is obtained and shows a regular narrow-complex tachycardia at approximately 150 bpm with no clearly identifiable P waves distinct from the QRS complexes and no sawtooth flutter waves. Which is correct about the recording?

Accepted Answer

PSVT

Answer

P mitrale

Answer

Electromechanical dissociation

Answer

P pulmonale

Question 6

A 30-year-old male was brought to the ER after a car crash. On admission, pulse is weak with BP=80 / 60 mm Hg. ECG is shown below. Right heart catheter is placed. Which is the most consistent value with patient's diagnosis?

Accepted Answer

16 | 34 / 16 | 16

Answer

16 | 100 / 30 | 28

Answer

16 | 45 / 22 | 20

Answer

16 | 75 / 30 | 11

Question 7

The murmur of mitral regurgitation is best heard at

Accepted Answer

Cardiac apex

Answer

Tricuspid area

Answer

Aortic area

Answer

Pulmonary area

Question 8

Which of the following statements is correct regarding the Opening Snap (OS) in a patient of mitral stenosis?

Accepted Answer

OS moves closer to the second sound (S2) as the stenosis becomes more severe

Answer

OS is best heard at the second left intercostal space

Answer

OS is best heard with the bell of stethoscope

Answer

Intensity of OS becomes louder when the valve is calcified

Question 9

Which one of the following is correct with regard to Carey Coombs murmur?

Accepted Answer

Soft mid-diastolic murmur due to mitral valvulitis

Answer

Harsh early diastolic murmur due to aortic regurgitation

Answer

Soft systolic murmur due to mitral regurgitation

Answer

Blowing late systolic murmur due to aortic stenosis

Question 10

Consider the following statements for diagnosing ventricular aneurysm in a patient with recent myocardial infarction :
I. Paradoxical impulse on chest wall
II. Persistent ST elevation on ECG
III. Unusual bulge from cardiac silhouette on X-ray
IV. Presence of pulsus paradoxsus

Which of the above are correct?

Accepted Answer

I, II and III

Answer

II, III and IV

Answer

I and II only

Answer

I and IV

Cardiology — MCQs

Cardiology — MCQs

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