Pericardial Diseases — MCQs

10 questions

A patient presents with engorged neck veins, a blood pressure of 80/50 mmHg, and a pulse rate of 100 beats per minute following blunt trauma to the chest. The diagnosis is:

Most common presentation of cardiac lupus ?

Which of the following conditions should not be considered if JVP rises on deep inspiration?

All of the following may cause ST segment elevation on an EKG, except which of the following?

Which of the following findings is seen in pericardial tamponade?

The cardiac jelly formed around the heart tube during early development contributes to the formation of:

Aetiology of Dressler Syndrome is

A patient presents with shortness of breath. Vitals are HR = 120/min with BP = 90/60 mm Hg. Echocardiography shows diastolic collapse of the ventricles. What is the best management for this patient?

A 55-year-old woman with metastatic lung cancer presents with dyspnea and pedal edema. On examination, the jugular venous pressure is 10 cm, with a negative Kussmaul's sign. The heart sounds are diminished, and the lungs have bibasilar crackles. The electrocardiogram shows QRS complexes of variable height. For the patient with shortness of breath and peripheral edema, select the most likely diagnosis.

Q10

Diagnose the underlying medical disorder based on the ECG changes.

Pericardial Diseases Indian Medical PG Practice Questions and MCQs

Question 1: A patient presents with engorged neck veins, a blood pressure of 80/50 mmHg, and a pulse rate of 100 beats per minute following blunt trauma to the chest. The diagnosis is:

A. Pneumothorax
B. Right ventricular failure
C. Cardiac tamponade (Correct Answer)
D. Hemothorax

Explanation: ***Cardiac tamponade*** - The clinical presentation shows **two components of Beck's triad**: **engorged neck veins (elevated JVP)** and **hypotension** (80/50 mmHg). While muffled heart sounds (the third component) are not mentioned, this is not required for diagnosis. - The combination of **blunt chest trauma** and these symptoms strongly suggests fluid accumulation in the pericardial sac, compressing the heart and impairing its filling. - **Tachycardia** (100 bpm) represents a compensatory response to reduced cardiac output. *Pneumothorax* - While pneumothorax can cause respiratory distress and hypotension, it typically presents with **absent breath sounds** on the affected side and **hyperresonance to percussion**, which are not described. - Engorged neck veins are not characteristic of simple pneumothorax. **Tension pneumothorax** can cause distended neck veins and severe hypotension, but would also present with severe respiratory distress and tracheal deviation away from the affected side. *Right ventricular failure* - Right ventricular failure can cause **engorged neck veins** but usually presents with signs of systemic congestion like **peripheral edema** and hepatomegaly, developing over time. - This is not typically an acute, immediate consequence of blunt chest trauma. The **acute hypotension** and **tachycardia** are more indicative of obstructive shock (cardiac tamponade) rather than pump failure. *Hemothorax* - Hemothorax involves blood accumulation in the pleural space, leading to **absent breath sounds** and **dullness to percussion** on the affected side. - While it can cause hypotension and tachycardia due to **hypovolemic shock** from blood loss, **engorged neck veins** are not a feature. In fact, significant blood loss typically causes **flat or collapsed neck veins** due to reduced venous return.

Question 2: Most common presentation of cardiac lupus ?

A. Aortic regurgitation
B. Libman sacks endocarditis
C. Myocarditis
D. Pericarditis (Correct Answer)

Explanation: ***Pericarditis*** - **Pericarditis** is the most common cardiac manifestation of **systemic lupus erythematosus (SLE)**, affecting a significant proportion of patients. - It often presents as **chest pain** that improves with leaning forward and worsens with lying down, along with a **pericardial friction rub** [3]. *Aortic regurgitation* - While **valvular disease** can occur in lupus, **aortic regurgitation** is less common than pericarditis as the initial or most frequent cardiac presentation. - Valvular involvement, particularly **Libman-Sacks endocarditis**, can sometimes lead to regurgitation, but is itself less common than pericardial involvement [2]. *Libman sacks endocarditis* - **Libman-Sacks endocarditis** involves **non-infectious vegetative lesions** on heart valves, typically the mitral or aortic valves. - Although characteristic of lupus, it is a less frequent presentation compared to **pericarditis** and can lead to valvular dysfunction. *Myocarditis* - **Myocarditis**, or inflammation of the heart muscle, is a less common but more serious cardiac manifestation of SLE [1]. - It can cause **heart failure** and **arrhythmias** but is not the most common initial presentation.

Question 3: Which of the following conditions should not be considered if JVP rises on deep inspiration?

A. Complete heart block
B. Constrictive pericarditis
C. Restrictive cardiomyopathy
D. Atrial fibrillation (Correct Answer)

Explanation: The phenomenon of JVP rising on deep inspiration is known as **Kussmaul's sign**, which is indicative of impaired right ventricular filling and is not typically associated with **atrial fibrillation**. In **complete heart block**, there is dissociation between atrial and ventricular contractions. This can lead to **cannon 'a' waves** in the JVP, which are large prominent 'a' waves caused by right atrial contraction against a closed tricuspid valve [1]. **Constrictive pericarditis** is characterized by a rigid pericardium that restricts diastolic filling of the right ventricle. This condition is a classic cause of **Kussmaul's sign**, where the JVP rises paradoxically during inspiration due to increased venous return that cannot be accommodated by the constricted ventricle. **Restrictive cardiomyopathy** involves impaired diastolic filling of the ventricles due to myocardial stiffness. It can also cause a paradoxical rise in JVP during inspiration (**Kussmaul's sign**) because the stiffened right ventricle cannot adequately accommodate the inspiratory increase in venous return.

Question 4: All of the following may cause ST segment elevation on an EKG, except which of the following?

A. Ventricular aneurysm
B. Prizmetal angina
C. Early repolarization variant
D. Constrictive pericarditis (Correct Answer)

Explanation: ***Constrictive pericarditis*** - While **pericarditis** can cause ST elevation due to inflammation of the epicardial layer [1], **constrictive pericarditis** primarily leads to **reduced diastolic filling** and rarely causes ST elevation. - ECG findings in constrictive pericarditis typically include **low voltage QRS complexes** and **T-wave flattening or inversion**, not ST elevation. *Early repolarization variant* - This is a **benign ECG finding** often seen in young, healthy individuals, characterized by **notching or slurring** at the end of the QRS complex (J-point elevation) with upwardly concave ST segments [1]. - It's a **normal variant** and not indicative of myocardial injury, despite the ST elevation. *Ventricular aneurysm* - A **ventricular aneurysm**, a non-contractile area of myocardial scar tissue, typically results in **persistent ST elevation** after an acute myocardial infarction in the leads corresponding to the aneurysm. - The ST elevation is usually **fixed** and observed in the setting of prior MI. *Prizmetal angina* - Also known as **vasospastic angina**, this condition involves **coronary artery spasm** causing transient myocardial ischemia, which manifests as **ST segment elevation** during episodes of chest pain. - The ST elevation resolves once the spasm ceases, differentiating it from an STEMI.

Question 5: Which of the following findings is seen in pericardial tamponade?

A. Beck's triad
B. Kussmaul sign
C. Pulsus paradoxus (Correct Answer)
D. All of the options

Explanation: ***Pulsus paradoxus*** - This is an **abnormally large decrease** in systolic blood pressure (>10 mmHg) and pulse wave amplitude during inspiration. - It occurs due to compromised ventricular filling caused by **increased pericardial pressure** in tamponade [1]. *Beck's triad* - Beck's triad (hypotension, jugular venous distention, and muffled heart sounds) are **signs/symptoms** of pericardial tamponade, not a finding in the same way pulsus paradoxus is [1]. - This clinical triad points towards the diagnosis but does not describe a physiological finding as specifically as pulsus paradoxus. *Kussmaul sign* - The Kussmaul sign is a paradoxical **increase** in jugular venous pressure (JVP) during inspiration. - While it indicates impaired right ventricular filling, it is classically seen in **constrictive pericarditis** and severe right heart failure, not typically in pericardial tamponade [2]. *All of the options* - This option is incorrect because Kussmaul sign is typically associated with **constrictive pericarditis** rather than pericardial tamponade [2]. - While Beck's triad is characteristic of tamponade, pulsus paradoxus is a specific hemodynamic finding seen in this condition [1].

Question 6: The cardiac jelly formed around the heart tube during early development contributes to the formation of:

A. Pericardium
B. Mesocardium
C. Myocardium
D. Endocardium (Correct Answer)

Explanation: Endocardium (Endocardial Cushions/Valves/Septa) - The **cardiac jelly** is an acellular, gelatinous matrix rich in **hyaluronic acid** that lies between the endocardium and the primordial myocardium during early heart development. - It undergoes **endothelial-to-mesenchymal transformation (EMT)** to form the **endocardial cushions** [1]. - These cushions are critical for forming: - **Atrioventricular (AV) valves** (mitral and tricuspid) [1] - **Semilunar valves** (aortic and pulmonary) [1] - **Cardiac septa** (portions of atrial, ventricular, and AV septa) [1] - While cardiac jelly doesn't form the endocardial lining itself (which is already present as endothelium), it forms the endocardial cushions that are essential endocardial derivatives. *Pericardium* - The **pericardium** develops from the **pleuropericardial folds** and **somatic and splanchnic mesoderm**, forming the fibrous and serous outer coverings of the heart. - It is completely distinct from cardiac jelly, which is an intra-cardiac structure. *Mesocardium* - The **dorsal mesocardium** is a transient mesentery that temporarily connects the developing heart tube to the dorsal wall of the pericardial cavity. - It rapidly degenerates by **day 22-23** to form the **transverse pericardial sinus**. - It does not contribute to cardiac jelly or any heart wall structures. *Myocardium* - The **myocardium** differentiates directly from the **splanchnic mesoderm** surrounding the endocardial tube. - It forms the muscular contractile layer of the heart wall. - Cardiac jelly lies between the endocardium and myocardium but does not form myocardial tissue.

Question 7: Aetiology of Dressler Syndrome is

A. Autoimmune (Correct Answer)
B. Toxin mediated
C. Viral infection
D. Idiopathic cause

Explanation: ***Autoimmune*** - Dressler syndrome is a form of **pericarditis** that occurs several days to weeks after myocardial injury (e.g., myocardial infarction, cardiac surgery, trauma). [3] - It is considered an **autoimmune phenomenon** where the body's immune system attacks damaged cardiac tissue. [1] *Viral infection* - While viral infections can cause general pericarditis, Dressler syndrome specifically refers to **post-cardiac injury** inflammation, not direct viral involvement. [2], [3] - Viral pericarditis typically has a more acute presentation without a preceding cardiac event. [2] *Toxin mediated* - There is no evidence to suggest that Dressler syndrome is caused by **toxins** or toxic substances. - The pathogenesis is linked to an immune response to damaged myocardial cells. *Idiopathic cause* - While some forms of pericarditis are idiopathic, Dressler syndrome has a clear **triggering event** (cardiac injury) and a well-understood autoimmune mechanism. [3] - Therefore, it is not classified as idiopathic. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 214-215. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, pp. 581-582. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 297-298.

Question 8: A patient presents with shortness of breath. Vitals are HR = 120/min with BP = 90/60 mm Hg. Echocardiography shows diastolic collapse of the ventricles. What is the best management for this patient?

A. Start diuretic with BP monitoring
B. Intra-aortic balloon pump
C. Pericardiocentesis (Correct Answer)
D. Ventricular assist device

Explanation: **Pericardiocentesis** * The constellation of **tachycardia**, **hypotension**, and **diastolic collapse of the ventricles** on echocardiography is highly suggestive of **cardiac tamponade**, a life-threatening condition [1]. * **Pericardiocentesis** is the definitive treatment for cardiac tamponade, as it relieves the pressure on the heart by draining the pericardial fluid, thereby restoring cardiac output and improving hemodynamics [1]. * *Start diuretic with BP monitoring* * Administering **diuretics** would further decrease intravascular volume and worsen already compromised cardiac output in the setting of hypotension due to cardiac tamponade. * While **blood pressure monitoring** is essential, diuretics are contraindicated and would exacerbate the patient's hemodynamic instability. * *Intra-aortic balloon pump* * An **intra-aortic balloon pump (IABP)** primarily assists in improving **coronary perfusion** and reducing **afterload** in conditions like cardiogenic shock or severe heart failure. * An IABP does not address the fundamental problem of external compression of the heart in cardiac tamponade and would not relieve the diagnostic finding of diastolic collapse of the ventricles. * *Ventricular assist device* * A **ventricular assist device (VAD)** is used to support failing ventricles by pumping blood from the heart to the rest of the body, typically in cases of advanced heart failure. * A VAD does not resolve the external compression on the heart caused by pericardial fluid in cardiac tamponade and is an invasive measure not indicated as a primary treatment in this scenario.

Question 9: A 55-year-old woman with metastatic lung cancer presents with dyspnea and pedal edema. On examination, the jugular venous pressure is 10 cm, with a negative Kussmaul's sign. The heart sounds are diminished, and the lungs have bibasilar crackles. The electrocardiogram shows QRS complexes of variable height. For the patient with shortness of breath and peripheral edema, select the most likely diagnosis.

A. Cardiac tamponade (Correct Answer)
B. Constrictive pericarditis
C. Restrictive cardiomyopathy
D. Right ventricle myocardial infarction (RVMI)

Explanation: ***Cardiac tamponade*** - The combination of **dyspnea**, **pedal edema**, **elevated JVP** with a **negative Kussmaul's sign**, **diminished heart sounds**, and **electrical alternans** (QRS complexes of variable height) suggests cardiac tamponade [2]. - The patient's history of **metastatic lung cancer** increases the likelihood of **pericardial effusion**, which can lead to tamponade [2]. *Constrictive pericarditis* - This condition typically presents with a **positive Kussmaul's sign**, which is absent in this patient. - **Electrical alternans** is not a characteristic feature of constrictive pericarditis. *Restrictive cardiomyopathy* - While it can cause **dyspnea** and **edema**, it is not typically associated with **diminished heart sounds** or **electrical alternans**. - The primary defect is in **ventricular filling** due to myocardial stiffness, not external compression. *Right ventricle myocardial infarction (RVMI)* - RVMI causes right heart failure, leading to **elevated JVP** and **pedal edema**, but it does not cause **diminished heart sounds** or **electrical alternans** [1]. - It also usually presents with symptoms of **ischemia** and specific **ECG changes** (e.g., ST elevation in right precordial leads), which are not mentioned.

Question 10: Diagnose the underlying medical disorder based on the ECG changes.

A. ECG changes due to hypokalemia
B. ECG changes due to hypercalcemia
C. ECG changes due to hypocalcemia (Correct Answer)
D. ECG changes due to hyperkalemia

Explanation: ***ECG changes due to hypocalcemia*** - **Hypocalcemia** characteristically causes a **prolonged QT interval** on the ECG due to delayed repolarization of ventricular myocytes. - This prolongation is primarily due to the lengthening of the **ST segment**, while the T wave itself is usually unchanged. *ECG changes due to hypokalemia* - **Hypokalemia** typically presents with prominent **U waves**, T wave flattening or inversion, and sometimes ST segment depression. - While it can also prolong the QT interval, the primary distinguishing feature is the presence of U waves, which are not mentioned as the main finding. *ECG changes due to hypercalcemia* - **Hypercalcemia** is associated with a **shortened QT interval** on the ECG due to accelerated repolarization. - It can also cause a shortened ST segment and widened QRS complex in severe cases. *ECG changes due to hyperkalemia* - **Hyperkalemia** classically manifests as tall, **peaked T waves**, followed by a prolonged PR interval, widened QRS complex, and eventual sine wave pattern as it worsens. - These changes are distinctly different from the prolonged QT interval seen in hypocalcemia.

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