Cardiology Practice Questions

Q: Continuous murmur is heard in?

Patent ductus arteriosus. ***Patent ductus arteriosus*** - A **continuous murmur** in PDA is often described as a **"machinery-like" murmur**, audible throughout systole and diastole [1]. - This murmur is caused by the continuous flow of blood from the higher-pressure aorta into the lower-pressure pulmonary artery [1]. *Tetralogy of Fallot* - The murmur associated with Tetralogy of Fallot is typically a **systolic ejection murmur** heard at the upper left sternal border [1]. - This murmur is due to pulmonary stenosis and is not continuous, as it is related to ventricular ejection [1]. *Ventricular septal defect* - A VSD typically presents with a **holosystolic murmur**, meaning it is heard throughout systole [1]. - The murmur in VSD is confined to systole and does not extend into diastole, distinguishing it from a continuous murmur [1]. *Atrial septal defect* - An ASD is typically associated with a **systolic ejection murmur** over the pulmonic area due to increased flow across the pulmonary valve [1]. - There may also be a **diastolic rumble** across the tricuspid valve, but neither of these is a continuous murmur [1].

Q: Which of the following is seen in mitral stenosis?

Diastolic murmur. ***Diastolic murmur*** - **Mitral stenosis** is characterized by a narrowing of the mitral valve, impeding blood flow from the left atrium to the left ventricle during **diastole**. - This turbulent flow during ventricular filling produces a characteristic **diastolic murmur**, often described as a low-pitched, rumbling sound [1], [3]. *None of the options* - This option is incorrect because **mitral stenosis** is indeed associated with a specific heart sound abnormality [1]. - The presence of a **diastolic murmur** is a hallmark physical finding in patients with mitral stenosis [1]. *Systolic murmur* - A **systolic murmur** is produced during ventricular contraction (systole), typically associated with **mitral regurgitation** or **aortic stenosis** [2]. - In **mitral stenosis**, the primary pathology is during diastole, making a systolic murmur less characteristic unless there's concomitant mitral regurgitation. *Loud S2* - A **loud S2** (second heart sound) can be heard in conditions like **pulmonary hypertension** or **systemic hypertension**. - While pulmonary hypertension can be a complication of severe **mitral stenosis** due to elevated left atrial pressure, a loud S2 is not the most direct or specific auscultatory finding for mitral stenosis itself; the distinct diastolic murmur is more characteristic [1].

Q: A patient after valve replacement will require follow up treatment with

Warfarin. ***Warfarin*** - Patients with **mechanical prosthetic heart valves** require lifelong anticoagulation with **warfarin** to prevent life-threatening thromboembolic complications [1]. - The target **international normalized ratio (INR)** typically ranges from 2.5 to 3.5, depending on the valve type and position. *ACE inhibitors* - **ACE inhibitors** are primarily used for managing **hypertension**, **heart failure**, and **renal protection**, not as routine post-valve replacement prophylaxis [2]. - While they may be used if these co-morbidities exist, they are not a universal requirement after valve surgery. *Beta blockers* - **Beta blockers** are often prescribed to control heart rate, manage **hypertension**, or reduce myocardial oxygen demand, but they are not the primary follow-up treatment for all valve replacement patients. - They do not address the critical need for **anticoagulation** in mechanical valve recipients. *Thiazide* - **Thiazide diuretics** are used to treat **hypertension** and **edema** by increasing salt and water excretion. - They do not play a direct role in preventing **thromboembolism** post-valve replacement and are not generally indicated unless chronic heart failure or hypertension is present.

Q: Which heart sound is almost always considered pathological?

S4. ***S4*** - An **S4 heart sound**, or **atrial gallop**, is almost always indicative of **pathology**, specifically a **stiff or non-compliant ventricle**. - It occurs due to vigorous atrial contraction forcing blood into a **non-compliant ventricle**, commonly seen in conditions like **hypertensive heart disease**, **aortic stenosis**, and **hypertrophic cardiomyopathy**. *S2* - **S2** represents the **closure of the aortic and pulmonic valves** and is a normal physiological heart sound [2]. - While it can be altered in pathology (e.g., fixed splitting, paradoxical splitting), the sound itself is a normal component of the cardiac cycle [1]. *S1* - **S1** represents the **closure of the mitral and tricuspid valves** and is a normal physiological heart sound [1]. - Variations in its intensity or splitting can occur in disease states, but the presence of S1 itself is normal. *S3* - An **S3 heart sound**, or **ventricular gallop**, can be a normal finding in **children**, **young adults**, and **pregnant individuals**, often referred to as a **physiological S3**. - However, in adults over 40, an S3 often indicates **ventricular dysfunction** due to rapid filling into a dilated ventricle [3], as seen in **heart failure** [1].

Q: Single heart sound (S2) is heard in:

Tetralogy of Fallot. ***Tetralogy of Fallot*** - A **single S2 heart sound** is characteristic of Tetralogy of Fallot due to the **pulmonary stenosis** (or atresia) which prevents the closure sound of the pulmonary valve from being heard [1]. - The single S2 heard is typically the **aortic component** (A2), as the pulmonary component (P2) is diminished or absent [1]. *Transposition of great vessels* - This condition is often associated with a **loud, single S2** because the aorta arises from the right ventricle, but a split S2 can occur if there is a large patent ductus arteriosus or ventricular septal defect. - The S2 is usually composed mainly of the **aortic component**, which is anteriorly placed. *Ebstein's anomaly* - Characterized by the downward displacement of the **tricuspid valve leaflets** into the right ventricle. - This typically results in a **wide, fixed splitting of S2** and can be associated with a gallop rhythm due to S3 and S4 sounds [2]. *TAPVC (Total Anomalous Pulmonary Venous Connection)* - TAPVC typically presents with a **widely split and fixed S2** due to increased blood flow through the pulmonary circulation. - When there is an obstruction, the P2 component can be louder, and a **gallop rhythm** might be present, but a single S2 is not a primary feature.

Q: On ECG, ST segment elevation is seen in all of the following conditions EXCEPT:

Hypocalcemia. ***Hypocalcemia*** - While hypocalcemia affects cardiac electrical activity by prolonging the **QT interval**, it is not typically associated with **ST segment elevation**. [3] - The primary ECG finding in hypocalcemia is a **prolonged ST segment**, which then leads to a prolonged QT interval, not an elevated ST segment. *Acute pericarditis* - Characteristically presents with **diffuse concave ST segment elevation** in many leads, often accompanied by **PR segment depression**. - This is due to inflammation of the pericardium affecting the epicardial layer of the myocardium. *Myocardial infarction* - **ST segment elevation** is a hallmark of an acute **ST-segment elevation myocardial infarction (STEMI)**, indicating transmural ischemia. [1], [2] - The location of ST elevation corresponds to the affected coronary artery and myocardial territory. [4] *Left ventricular aneurysm* - Can cause **persistent ST segment elevation** in the leads corresponding to the aneurysm, even after the acute phase of a myocardial infarction. - This persistent elevation is thought to be due to **dyskinetic or akinetic wall motion** and altered repolarization in the scarred tissue.

Q: Which of the following is not true regarding Wolff-Parkinson-White (WPW) syndrome?

Prolonged PR interval. ***Prolonged PR interval*** - In WPW syndrome, the presence of an **accessory pathway (Bundle of Kent)** allows for **pre-excitation** of the ventricles, bypassing the AV node's normal delay [1]. - This results in a **shortened PR interval** (typically < 0.12 seconds), not a prolonged one [1]. *Delta wave is seen on ECG* - The **delta wave** is a characteristic finding in WPW, representing the slurred upstroke of the QRS complex due to early ventricular activation via the accessory pathway [1]. - It indicates **ventricular pre-excitation** and is a key diagnostic feature [1], [2]. *Bundle of Kent connects atria to ventricles* - The **Bundle of Kent** is an anomalous muscle fiber bundle that forms an **accessory pathway** directly connecting the atria to the ventricles [1]. - This pathway bypasses the AV node, leading to the characteristic ECG findings and potential re-entrant arrhythmias. *Pre-excitation occurs via accessory pathway* - **Pre-excitation** is the hallmark of WPW syndrome, where electrical impulses bypass the normal conduction system (AV node) and activate ventricular tissue prematurely via an **accessory pathway** [1]. - This leads to the characteristic short PR interval and delta wave on the ECG [2].

Q: Pressure difference of 5 mm Hg between the two upper limbs occurs in which congenital heart disease?

Supra-valvular aortic stenosis. ***Supra-valvular aortic stenosis*** - **Supravalvular aortic stenosis** causes a **pressure gradient** across the aortic valve, leading to a significant **pressure difference** between the upper limbs, typically with a **higher pressure** in the right arm. - This is due to the **Coanda effect**, where the high-velocity jet of blood preferentially flows up the **right subclavian artery** as it exits the aorta. *HOCM (Hypertrophic Obstructive Cardiomyopathy)* - HOCM is characterized by hypertrophy of the **left ventricular septum** causing **outflow tract obstruction**, but it does not typically cause a significant **pressure difference** between the upper limbs. - The obstruction primarily affects **ventricular ejection** rather than differential flow to major arteries. *Coarctation of Aorta* - **Coarctation of the aorta** causes a significant **blood pressure difference** between the upper and lower extremities, with higher pressures in the arms [1]. - However, it does not typically cause a marked **pressure difference between the two upper limbs**, unless the coarctation is pre-ductal and affects the subclavian artery circulation asymmetrically, which is less common for a difference of just 5 mmHg. *TOF (Tetralogy of Fallot)* - **Tetralogy of Fallot** is a cyanotic heart disease involving **pulmonary stenosis**, ventricular septal defect, overriding aorta, and right ventricular hypertrophy [2]. - While it causes significant circulatory abnormalities and potential for **hypoxia**, it does not inherently lead to a measurable **pressure difference** between the upper limbs.

Q: Angle of tracheal bifurcation is increased in which chamber of heart enlargement.

Left atrium. ***Left atrium*** - An enlarged **left atrium** can lift the **left main bronchus**, increasing the angle between the two main bronchi, known as the **carinal angle** (or angle of tracheal bifurcation), visible on a chest X-ray. - This is a common radiological sign seen in conditions causing left atrial enlargement, such as **mitral stenosis** [2]. *Left ventricle* - **Left ventricular enlargement** primarily causes the cardiac apex to shift downward and laterally, but it typically does not directly impinge on the main bronchi to increase the carinal angle [1]. - While it can indirectly affect lung fields due to **pulmonary congestion**, it doesn't cause this specific sign [1]. *Right atrium* - **Right atrial enlargement** causes a bulging of the right border of the heart on a chest X-ray [1]. - It does not directly interact with or displace the main bronchi in a way that would alter the **tracheal bifurcation angle**. *Right ventricle* - **Right ventricular enlargement** can cause the heart to push into the retrosternal space and elevate the apex, but it generally does not impinge upon the main bronchi to change the **carinal angle** [1]. - Its effects are more focused on the anterior and rightward aspects of the heart.

Q: Differential cyanosis is seen in

PDA. ***PDA*** - **Differential cyanosis** occurs in **Patent Ductus Arteriosus (PDA)** with **pulmonary hypertension** and **reversed shunt** [1]. - Deoxygenated blood from the pulmonary artery shunts into the **descending aorta** distal to the subclavian artery, leading to cyanosis in the lower extremities, typically sparing the right upper extremity unless there is a pre-ductal coarctation or an anomalous right subclavian artery from the descending aorta. *All of the options* - This is incorrect because differential cyanosis is a specific finding associated predominantly with **right-to-left shunting** through a patent ductus arteriosus. - While other congenital heart defects can cause cyanosis, few cause the distinct pattern of differential cyanosis. *VSD* - **Ventricular Septal Defect (VSD)** typically causes a **left-to-right shunt**, leading to increased pulmonary blood flow, and eventually pulmonary hypertension [2]. - If Eisenmenger syndrome develops with a **reverses shunt (right-to-left)**, it would cause **generalized cyanosis**, not differential cyanosis, as the shunting occurs at the ventricular level before the great arteries diverge. *ASD* - **Atrial Septal Defect (ASD)** creates a **left-to-right shunt** at the atrial level, increasing pulmonary blood flow [3]. - The development of **Eisenmenger syndrome** with a right-to-left shunt in ASD would also lead to **generalized cyanosis** because deoxygenated blood mixes in the left atrium before being ejected into the systemic circulation.

Question 1

Continuous murmur is heard in?

Accepted Answer

Patent ductus arteriosus

Answer

Tetralogy of fallot

Answer

Ventricular septal defect

Answer

Atrial septal defect

Question 2

Which of the following is seen in mitral stenosis?

Accepted Answer

Diastolic murmur

Answer

None of the options

Answer

Systolic murmur

Answer

Loud S2

Question 3

A patient after valve replacement will require follow up treatment with

Accepted Answer

Warfarin

Answer

ACE inhibitors

Answer

Beta blockers

Answer

Thiazide

Question 4

Which heart sound is almost always considered pathological?

Accepted Answer

S4

Answer

S2

Answer

S1

Answer

S3

Question 5

Single heart sound (S2) is heard in:

Accepted Answer

Tetralogy of Fallot

Answer

Transposition of great vessels

Answer

Ebstein's anomaly

Answer

TAPVC

Question 6

On ECG, ST segment elevation is seen in all of the following conditions EXCEPT:

Accepted Answer

Hypocalcemia

Answer

Acute pericarditis

Answer

Myocardial infarction

Answer

Left ventricular aneurysm

Question 7

Which of the following is not true regarding Wolff-Parkinson-White (WPW) syndrome?

Accepted Answer

Prolonged PR interval

Answer

Delta wave is seen on ECG

Answer

Bundle of Kent connects atria to ventricles

Answer

Pre-excitation occurs via accessory pathway

Question 8

Pressure difference of 5 mm Hg between the two upper limbs occurs in which congenital heart disease?

Accepted Answer

Supra-valvular aortic stenosis

Answer

HOCM

Answer

Coarctation of Aorta

Answer

TOF

Question 9

Angle of tracheal bifurcation is increased in which chamber of heart enlargement.

Accepted Answer

Left atrium

Answer

Left ventricle

Answer

Right atrium

Answer

Right ventricle

Question 10

Differential cyanosis is seen in

Accepted Answer

PDA

Answer

All of the options

Answer

VSD

Answer

ASD

Cardiology — MCQs

Cardiology — MCQs

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