Cardiology — MCQs

A 55-year-old woman presents with complaints of chest pain. She states that the chest pain predictably occurs when she climbs four flights of stairs to reach her apartment or when she has been jogging for more than 10 minutes. She is particularly concerned because her mother died of a myocardial infarction at 50 years of age. Which of the following best describes this patient's state?

Q949Medium

A 65-year-old man with a history of syncopal attacks on exertion and angina is undergoing heart valve surgery. Which kind of pulse is expected to be present before surgery?

Q950Easy

Ewa's sign is seen in:

Cardiology Indian Medical PG Practice Questions and MCQs

Question 941: Which of the following is not a major Framingham criterion for heart failure?

A. Cardiomegaly
B. Paroxysmal nocturnal dyspnea
C. S3 gallop
D. Hepatomegaly (Correct Answer)

Explanation: To diagnose Heart Failure (HF) using the **Framingham Criteria**, a patient must fulfill **two major criteria** or **one major and two minor criteria**. [1] ### **Why Hepatomegaly is the Correct Answer** **Hepatomegaly** is classified as a **Minor Criterion**. In the Framingham study, minor criteria represent signs and symptoms that are less specific to heart failure and can be caused by other conditions (e.g., liver disease or chronic lung disease). Other minor criteria include bilateral ankle edema, nocturnal cough, dyspnea on exertion, tachycardia (>120 bpm), and pleural effusion. ### **Analysis of Incorrect Options (Major Criteria)** The following are **Major Criteria** because they have a high specificity for the diagnosis of congestive heart failure: * **A. Cardiomegaly:** Detected on chest X-ray; indicates ventricular dilatation. [1] * **B. Paroxysmal Nocturnal Dyspnea (PND):** A highly specific symptom where the patient wakes up gasping for air. [1] * **C. S3 Gallop:** A classic physical sign of ventricular filling into a dilated, non-compliant chamber. [1] ### **High-Yield Clinical Pearls for NEET-PG** * **The "Weight Loss" Rule:** Weight loss of >4.5 kg in 5 days in response to treatment (diuretics) can be considered either a major or minor criterion depending on the clinical context. * **Other Major Criteria to Remember:** * Neck vein distention (JVP) * Acute pulmonary edema * Hepatojugular reflux [1] * Rales (crackles) [1] * **Mnemonic for Major Criteria:** **"SAUCE PAN"** (S3, Acute pulmonary edema, Upper venous congestion/JVP, Cardiomegaly, Effusion—not pleural, but weight loss from diuresis, PND, Ankle edema is minor, Neck vein distention). * **Note:** For NEET-PG, remember that **Hepatomegaly** and **Peripheral Edema** are frequently tested distractors; they are **Minor**, not Major.

Question 942: Pulsus paradoxus is present in all of the following conditions except:

A. Hypovolemic shock
B. Pulmonary embolism
C. Right ventricular myocardial infarction (Correct Answer)
D. Cardiac tamponade

Explanation: **Explanation:** **Pulsus paradoxus** is defined as an exaggerated decrease in systolic blood pressure (>10 mmHg) during inspiration. Under normal physiological conditions, inspiration increases venous return to the right heart, causing the interventricular septum to bulge slightly into the left ventricle (LV), minimally reducing LV stroke volume. **Why Right Ventricular Myocardial Infarction (RVMI) is the Correct Answer:** In **RVMI**, the right ventricle is akin to a stiff, non-compliant bag [2]. It cannot accommodate an increase in venous return during inspiration. Consequently, there is no significant septal shift toward the left ventricle. Furthermore, the hallmark of RVMI is elevated jugular venous pressure (JVP) that *increases* during inspiration (**Kussmaul’s sign**), rather than pulsus paradoxus. **Analysis of Incorrect Options:** * **Cardiac Tamponade:** This is the classic cause. The heart is compressed within a fixed pericardial space; increased right-sided filling during inspiration forces the septum to bulge significantly into the LV, severely reducing stroke volume [1]. * **Pulmonary Embolism:** Acute right heart strain and increased pulmonary artery pressure lead to RV dilation, causing a leftward septal shift and pulsus paradoxus [3]. * **Hypovolemic Shock:** Reduced intravascular volume exacerbates the respiratory fluctuations in stroke volume, leading to a paradoxical pulse [4]. **NEET-PG High-Yield Pearls:** 1. **Kussmaul’s Sign vs. Pulsus Paradoxus:** Kussmaul’s sign (rise in JVP on inspiration) is seen in Constrictive Pericarditis and RVMI. Pulsus paradoxus is classic for Cardiac Tamponade. 2. **Non-Cardiac Causes:** Severe Asthma and COPD are common non-cardiac causes of pulsus paradoxus due to extreme intrathoracic pressure swings. 3. **Exception:** Pulsus paradoxus is **absent** in tamponade if there is co-existing Aortic Regurgitation or Atrial Septal Defect.

Question 943: A 70-year-old man with a past medical history of ischemic heart disease and hypertension presents to his GP with recurrent episodes of syncope over the past 2 weeks. Based upon this ECG, which of the following clinical findings is most likely to be present?

A. Absent JVP
B. Canon A waves (Correct Answer)
C. Absent hepato-jugular reflux
D. Giant V waves

Explanation: ***Canon A waves*** - **Complete heart block (3rd degree AV block)** causes **AV dissociation** where atria and ventricles beat independently, leading to occasional simultaneous atrial and ventricular contractions. - When the **right atrium contracts against a closed tricuspid valve**, it creates prominent **canon A waves** in the jugular venous pulse, which is pathognomonic for complete heart block. *Absent JVP* - The **jugular venous pulse (JVP)** would still be visible in complete heart block, though it may show irregular patterns due to **AV dissociation**. - **Canon A waves** are actually a prominent feature of the JVP in this condition, making absent JVP unlikely. *Absent hepato-jugular reflux* - The **hepato-jugular reflux** test assesses **right heart function** and venous return, which are not directly affected by conduction abnormalities. - Complete heart block primarily affects **electrical conduction**, not the mechanical function of venous return or right heart filling. *Giant V waves* - **Giant V waves** in the JVP indicate severe **tricuspid regurgitation** due to incompetent tricuspid valve during ventricular systole. - Complete heart block causes **conduction abnormalities** rather than valvular incompetence, making giant V waves an unlikely finding.

Question 944: Atrial fibrillation may occur in all of the following conditions, except?

A. Mitral stenosis
B. Hypothyroidism (Correct Answer)
C. Dilated cardiomyopathy
D. Mitral regurgitation

Explanation: ### Explanation Atrial Fibrillation (AF) is typically triggered by structural remodeling, atrial stretch, or increased sympathetic activity [1]. **Why Hypothyroidism is the correct answer:** In thyroid disorders, **Hyperthyroidism** is a classic and frequent cause of AF due to increased sensitivity to catecholamines and direct effects of T3 on the myocardium [1]. Conversely, **Hypothyroidism** is associated with **bradyarrhythmias** (sinus bradycardia) and conduction blocks. While severe hypothyroidism (Myxedema) can rarely cause QT prolongation, it is not a recognized cause of AF. **Analysis of Incorrect Options:** * **Mitral Stenosis (MS):** This is the most common valvular cause of AF. Chronic pressure overload leads to significant left atrial (LA) enlargement and fibrosis, disrupting normal electrical conduction. * **Mitral Regurgitation (MR):** Similar to MS, chronic volume overload in MR leads to LA dilatation, which is a potent substrate for the development of AF. * **Dilated Cardiomyopathy (DCM):** The global enlargement of heart chambers and replacement fibrosis in DCM increase atrial wall stress, making AF a very common complication and a marker of poor prognosis. **NEET-PG High-Yield Pearls:** * **Most common cause of AF (Global):** Hypertension and Coronary Artery Disease. * **Most common valvular cause:** Mitral Stenosis. * **Holiday Heart Syndrome:** AF triggered by acute alcohol consumption. * **Lone AF:** AF occurring in patients <60 years old with no clinical or echocardiographic evidence of cardiopulmonary disease. * **ECG Hallmark:** "Irregularly irregular" rhythm with absent P-waves and presence of f-waves [1].

Question 945: A patient with acute inferior wall myocardial infarction has developed shock. Which of the following is the most likely cause of shock?

A. Cardiac rupture
B. Interventricular septal perforation
C. Papillary muscle rupture
D. Right ventricular infarction (Correct Answer)

Explanation: In the setting of an **Acute Inferior Wall Myocardial Infarction (IWMI)**, the development of shock is most commonly attributed to **Right Ventricular Infarction (RVI)**. This occurs because the Right Coronary Artery (RCA) typically supplies both the inferior wall of the left ventricle and the right ventricle [1]. **Why Right Ventricular Infarction is correct:** RVI leads to right-sided heart failure, resulting in decreased preload to the left ventricle. This manifests as the classic triad of **hypotension, clear lung fields, and elevated Jugular Venous Pressure (JVP)** (Kussmaul’s sign). It is the most frequent complication causing hemodynamic instability specifically in IWMI patients [1]. **Why other options are incorrect:** * **Cardiac Rupture (Free Wall):** Usually occurs 3–7 days post-MI, leading to sudden cardiac tamponade and PEA (Pulseless Electrical Activity) [2]. It is less common than RVI in the immediate acute phase. * **Interventricular Septal Perforation:** Causes a left-to-right shunt and "step-up" in oxygen saturation in the RV. While it causes shock, it typically presents with a harsh pansystolic murmur and is more common in anterior wall MIs. * **Papillary Muscle Rupture:** Leads to acute, severe mitral regurgitation and pulmonary edema. While it can occur with IWMI, the presence of **clear lungs** in the question's context strongly points toward RVI rather than the flash pulmonary edema seen here. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Best initial lead is **V4R** (ST-elevation >1mm). * **Management:** Avoid nitrates, diuretics, and morphine (which decrease preload). The mainstay of treatment is **aggressive IV fluid resuscitation** to maintain RV preload. * **Triad:** Hypotension + Clear Lungs + Raised JVP = RV Infarction.

Question 946: Which of the following produces a continuous murmur except?

A. Mitral valve prolapse (Correct Answer)
B. Arteriovenous malformations
C. Ruptured sinus of Valsalva
D. Patent ductus arteriosus

Explanation: A **continuous murmur** is defined as a murmur that begins in systole and continues through the second heart sound (S2) into all or part of diastole. This occurs when there is a persistent pressure gradient between two chambers or vessels throughout the entire cardiac cycle [1]. **Why Mitral Valve Prolapse (MVP) is the correct answer:** MVP typically produces a **mid-systolic click** [1] followed by a **late systolic murmur**. It is not a continuous murmur because the regurgitation occurs only when the ventricular pressure rises enough to prolapse the leaflets into the left atrium during systole. Once the aortic valve closes (S2) and diastole begins, the pressure gradient shifts, and the murmur ceases. **Analysis of Incorrect Options (Causes of Continuous Murmurs):** * **Patent Ductus Arteriosus (PDA):** The classic "Gibson’s murmur." Since aortic pressure is higher than pulmonary artery pressure in both systole and diastole, flow is continuous. * **Ruptured Sinus of Valsalva (RSOV):** Usually ruptures into the right ventricle or right atrium. Because aortic diastolic pressure remains higher than right-sided pressures, a continuous murmur is produced. * **Arteriovenous (AV) Malformations:** These create a direct communication between a high-pressure artery and a low-pressure vein, maintaining a gradient throughout the cycle. **Clinical Pearls for NEET-PG:** * **Most common cause of continuous murmur:** PDA. * **Venous Hum:** A benign continuous murmur heard in the neck (disappears with jugular vein compression or turning the head). * **Cruveilhier-Baumgarten Murmur:** A continuous murmur heard over the epigastrium due to collateral circulation in portal hypertension. * **Blalock-Taussig (BT) Shunt:** A surgical cause of a continuous murmur.

Question 947: Pulsus paradoxus is seen in all of the following EXCEPT:

A. Corpulmonale
B. Acute asthma
C. SVC obstruction
D. Mitral regurgitation (Correct Answer)

Explanation: Explanation: **Pulsus paradoxus** is defined as an exaggerated decrease in systolic blood pressure (>10 mmHg) during inspiration. Under normal physiological conditions, inspiration increases venous return to the right heart, causing the interventricular septum to bulge slightly into the left ventricle (LV), minimally reducing LV stroke volume. **Why Mitral Regurgitation (MR) is the correct answer:** In MR, the left ventricle is "overfilled" due to the constant volume overload from the left atrium [1]. This increased preload and the presence of a "safety valve" (the regurgitant flow back into the atrium) prevent the inspiratory shift of the septum from significantly compromising LV output. Therefore, pulsus paradoxus is **not** a feature of MR. In fact, MR is often associated with a *normal* or even *diminished* respiratory variation in blood pressure. **Why the other options are incorrect:** * **Acute Asthma & Cor Pulmonale:** These involve severe respiratory distress. Large negative intrathoracic pressures during inspiration increase systemic venous return while simultaneously increasing the pooling of blood in the expanded pulmonary vasculature. This significantly reduces LV filling, leading to pulsus paradoxus. * **SVC Obstruction:** While less common than in tamponade, severe SVC obstruction can cause pulsus paradoxus due to the marked changes in intrathoracic pressure dynamics and altered venous return patterns. **NEET-PG High-Yield Pearls:** * **Most Common Cause:** Cardiac Tamponade (Classic triad: Hypotension, JVP distension, muffled heart sounds) [2]. * **Kussmaul’s Sign vs. Pulsus Paradoxus:** Pulsus paradoxus is seen in Tamponade; Kussmaul’s sign (inspiratory rise in JVP) is typically seen in **Constrictive Pericarditis** (though CP can occasionally show both). * **Reverse Pulsus Paradoxus:** Seen in Hypertrophic Obstructive Cardiomyopathy (HOCM) and during positive pressure ventilation.

Question 948: A 55-year-old woman presents with complaints of chest pain. She states that the chest pain predictably occurs when she climbs four flights of stairs to reach her apartment or when she has been jogging for more than 10 minutes. She is particularly concerned because her mother died of a myocardial infarction at 50 years of age. Which of the following best describes this patient's state?

A. Arrhythmia
B. Myocardial infarction
C. Prinzmetal angina
D. Stable angina pectoris (Correct Answer)

Explanation: The patient’s presentation is classic for **Stable Angina Pectoris**. The hallmark of this condition is chest pain that is **predictable, reproducible, and occurs during physical exertion** (climbing stairs, jogging) or emotional stress [1]. It is caused by a fixed coronary artery stenosis (usually >70%) that creates a "demand-supply mismatch"—the blood flow is sufficient at rest but inadequate when myocardial oxygen demand increases [2]. The pain typically resolves with rest or sublingual nitroglycerin. **2. Why the Other Options are Incorrect:** * **Arrhythmia:** While arrhythmias can cause chest discomfort or palpitations, they do not typically present with this specific, predictable relationship to physical exertion. * **Myocardial Infarction (MI):** MI involves complete coronary occlusion leading to myocardial necrosis [4]. The pain is usually more severe, lasts >20 minutes, occurs at rest, and is not relieved by rest or nitrates. [4] * **Prinzmetal Angina:** Also known as variant angina, this is caused by coronary artery vasospasm. Unlike stable angina, it characteristically occurs **at rest**, often in the early morning hours, and is not triggered by exertion. **3. NEET-PG High-Yield Pearls:** * **Gold Standard Investigation:** Coronary Angiography (to visualize stenosis). * **Initial Investigation of Choice:** Exercise Stress Test (Treadmill Test/TMT) [3]. * **Pathophysiology:** Fixed atherosclerotic plaque (Stable Angina) vs. Plaque rupture/thrombosis (Acute Coronary Syndrome) [1]. * **Management:** Lifestyle modification, Beta-blockers (first-line for symptom control), Aspirin, and Statins. * **Clinical Definition:** Stable angina is defined by the "3 Ps": **P**redictable, **P**recipitated by exertion, and **P**romptly relieved by rest. [1]

Question 949: A 65-year-old man with a history of syncopal attacks on exertion and angina is undergoing heart valve surgery. Which kind of pulse is expected to be present before surgery?

A. Dicrotic pulse
B. Pulsus bigeminus
C. Pulsus bisferiens
D. Anacrotic pulse (Correct Answer)

Explanation: ### Explanation The clinical triad of **exertional syncope, angina, and dyspnea** in an elderly patient is the classic presentation of **Aortic Stenosis (AS)**. **1. Why Anacrotic Pulse is Correct:** In severe Aortic Stenosis, the narrowed valve orifice obstructs left ventricular outflow. This results in a pulse that is slow to rise and low in amplitude, known as **Pulsus Parvus et Tardus** [1]. When a palpable notch is felt on the ascending limb of the pulse wave, it is specifically termed an **Anacrotic pulse**. This occurs because the high pressure required to force blood through the stenotic valve creates a "hesitation" or notch during the initial upstroke. **2. Analysis of Incorrect Options:** * **Dicrotic Pulse:** Characterized by two peaks, one in systole and one in diastole (after the second heart sound). It is typically seen in states of very low cardiac output and high systemic vascular resistance, such as severe **Dilated Cardiomyopathy**. * **Pulsus Bigeminus:** A rhythm disorder where a normal beat is followed by a premature ventricular contraction (PVC). It is most commonly associated with **Digoxin toxicity**. * **Pulsus Bisferiens:** Features two systolic peaks. It is characteristic of **Aortic Regurgitation (AR)** or combined AS/AR, and **Hypertrophic Obstructive Cardiomyopathy (HOCM)**. **3. NEET-PG High-Yield Pearls:** * **Aortic Stenosis:** Look for a "Harsh Crescendo-Decrescendo" systolic murmur radiating to the carotids [1]. * **Pulsus Alternans:** Alternating strong and weak beats; a hallmark of **Left Ventricular Failure**. * **Water-hammer Pulse (Corrigan’s):** Large volume, collapsing pulse seen in **Aortic Regurgitation**. * **Pulsus Paradoxus:** An exaggerated drop in systolic BP (>10 mmHg) during inspiration; classic for **Cardiac Tamponade**.

Question 950: Ewa's sign is seen in:

A. Acute pulmonary embolism
B. Pericardial effusion (Correct Answer)
C. Pneumomediastinum
D. Chronic constrictive pericarditis

Explanation: **Explanation:** **Ewart’s sign** (often misspelled as Ewa's sign) is a clinical finding classically associated with **large pericardial effusions**. **Why the correct answer is right:** When a large amount of fluid accumulates in the pericardial sac, the distended sac compresses the base of the **left lung** (specifically the left lower lobe) against the posterior chest wall. This mechanical compression leads to a localized area of **compression atelectasis**. On physical examination, this manifests as a patch of dullness to percussion, bronchial breath sounds, and egophony found just below the **angle of the left scapula**. **Why incorrect options are wrong:** * **Acute pulmonary embolism:** Presents with sudden onset dyspnea, pleuritic chest pain, and tachycardia. While it can cause pleural effusion, it does not typically cause the specific posterior lung compression seen in Ewart’s sign. * **Pneumomediastinum:** Characterized by **Hamman’s sign** (a crunching sound heard over the precordium synchronous with the heartbeat), not lung compression findings. * **Chronic constrictive pericarditis:** This involves a thickened, fibrotic, and calcified pericardium that restricts cardiac filling. It does not typically involve the massive fluid volume required to compress the lung parenchyma. **High-Yield Clinical Pearls for NEET-PG:** * **Beck’s Triad (Cardiac Tamponade):** Hypotension, JVD, and muffled heart sounds. * **Electrical Alternans:** Pathognomonic ECG finding for large pericardial effusion/tamponade due to the "swinging heart" in fluid [1]. * **Water-bottle heart:** The characteristic globular cardiac silhouette seen on Chest X-ray in large effusions [1]. * **Pulsus Paradoxus:** An exaggerated drop in systolic BP (>10 mmHg) during inspiration, commonly seen in tamponade.

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Cardiology — MCQs

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