Cardiology — MCQs
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What is the risk of congenital heart disease in a first-degree relative?
Where is the innocent murmur best heard in children?
Which of the following is FALSE about Transposition of the Great Arteries (TGA)?
What is the most common congenital cardiac abnormality associated with maternal rubella infection during pregnancy?
In Tetralogy of Fallot, when does the foramen ovale close?
In a patient of rheumatic carditis, for how long is the full dose of steroid typically given?
A 2-year-old boy presented with signs of congested cardiac failure and a right-to-left shunt. What is the most likely diagnosis?
Peripheral pulmonic stenosis is associated with which of the following conditions?
Which of the following is considered one of Nada's major criteria for the clinical diagnosis of congenital heart disease?
A baby is born with a flat facial profile, prominent epicanthal folds, and a single palmar crease. The baby vomits when fed, and upper GI studies demonstrate gas in the stomach and duodenal bulb. Which of the following cardiovascular abnormalities might this child also have?
Cardiology Indian Medical PG Practice Questions and MCQs
Question 1: What is the risk of congenital heart disease in a first-degree relative?
- A. 0.5% to 0.6%
- B. 2% to 6% (Correct Answer)
- C. 5% to 6%
- D. 20% to 25%
Explanation: **Explanation:** The incidence of Congenital Heart Disease (CHD) in the general population is approximately **0.8% to 1%** (often cited as 8 per 1,000 live births). However, the risk increases significantly when a first-degree relative (parent or sibling) is affected. **1. Why Option B is Correct:** The inheritance of most CHDs is **multifactorial**, involving a combination of multiple genetic loci and environmental triggers. For most isolated cardiac defects, the recurrence risk for a first-degree relative is typically cited between **2% to 6%**. This represents a 3-to-5-fold increase over the baseline population risk. If two first-degree relatives are affected, the risk climbs further to approximately 10-15%. **2. Analysis of Incorrect Options:** * **Option A (0.5% to 0.6%):** This is lower than the baseline incidence in the general population (0.8-1%) and therefore incorrect. * **Option C (5% to 6%):** While 6% is the upper limit of the range, 5-6% as a standalone range is too narrow and overestimates the risk for many common lesions like VSD or PDA. * **Option D (20% to 25%):** This range is characteristic of **Autosomal Recessive** inheritance patterns. While some specific syndromes (e.g., Ellis-van Creveld) follow this, it does not apply to general CHD risk. **High-Yield Clinical Pearls for NEET-PG:** * **Left-sided obstructive lesions** (e.g., Bicuspid Aortic Valve, Hypoplastic Left Heart Syndrome) have the highest recurrence risk, sometimes reaching 10-15%. * If the **mother** has CHD, the risk to the offspring is generally higher (approx. 10-12%) compared to if the father is affected (approx. 2-3%). * **Most common CHD overall:** Ventricular Septal Defect (VSD). * **Most common CHD in Down Syndrome:** Atrioventricular Septal Defect (AVSD/Endocardial Cushion Defect).
Question 2: Where is the innocent murmur best heard in children?
- A. Pulmonic area
- B. Aortic area
- C. Left lower mid-sternal border (Correct Answer)
- D. Apex
Explanation: **Explanation:** The most common innocent murmur in children is the **Still’s Murmur**. It is a vibratory, musical, low-frequency systolic ejection murmur. It is characteristically heard best at the **left lower mid-sternal border (LLSB)** or the area between the LLSB and the apex. The sound is believed to originate from periodic vibrations of the chordae tendineae or the pulmonary valve leaflets during ventricular ejection. **Analysis of Options:** * **Left lower mid-sternal border (Correct):** This is the classic location for Still’s murmur, the most frequent innocent murmur in the pediatric population (typically ages 2–6 years). * **Pulmonic area (Incorrect):** While the *Innocent Pulmonary Ejection Murmur* is heard here, it is less common than Still’s murmur. Pathological murmurs like ASD or Pulmonary Stenosis are also localized here. * **Aortic area (Incorrect):** This area is typically associated with pathology such as Aortic Stenosis or Bicuspid Aortic Valve. * **Apex (Incorrect):** Murmurs at the apex in children often suggest Mitral Regurgitation (pathological). **Clinical Pearls for NEET-PG:** 1. **Features of Innocent Murmurs (The 7 S’s):** Sensitive (changes with position), Short (duration), Single (no clicks), Small (localized), Soft (low intensity), Sweet (musical), and Systolic. 2. **Positional Variation:** Still’s murmur is loudest in the **supine position** and decreases or disappears when the child sits or stands. 3. **Venous Hum:** Another common innocent murmur heard in the supraclavicular space; it is continuous and disappears when the child lies flat or when the jugular vein is compressed.
Question 3: Which of the following is FALSE about Transposition of the Great Arteries (TGA)?
- A. Cyanosis at birth
- B. Congestive Heart Failure (CHF)
- C. Ventricular Septal Defect (VSD)
- D. Aortic Stenosis (AS) (Correct Answer)
Explanation: **Explanation:** Transposition of the Great Arteries (TGA) is a cyanotic congenital heart disease where the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle, creating two parallel, independent circulations. **Why Aortic Stenosis (AS) is the correct answer (FALSE statement):** Aortic Stenosis is not a characteristic feature or a common association of TGA. In TGA, the primary hemodynamic issue is the transposition itself. While **Pulmonary Stenosis (PS)** is a frequent association (occurring in about 25% of cases and often protecting the lungs from over-circulation), Aortic Stenosis is not part of the typical clinical spectrum of TGA. **Analysis of Incorrect Options:** * **A. Cyanosis at birth:** This is the hallmark of TGA. It is the most common cause of "cyanosis at birth" or within the first 24 hours of life. Since the circulations are parallel, oxygenated blood does not reach the systemic circulation unless there is a shunt. * **B. Congestive Heart Failure (CHF):** CHF is common in TGA, especially when a large VSD is present. The high-pressure right ventricle must pump against systemic resistance, and increased pulmonary blood flow leads to volume overload. * **C. Ventricular Septal Defect (VSD):** Approximately 30-40% of TGA cases are associated with a VSD. A VSD actually improves mixing between the two circuits, often delaying the severity of initial cyanosis but increasing the risk of early CHF. **High-Yield Clinical Pearls for NEET-PG:** * **X-ray Finding:** "Egg-on-a-string" appearance (due to a narrow mediastinum and globular heart). * **Management:** Immediate administration of **PGE1** to keep the Ductus Arteriosus open; **Rashkind’s Procedure** (Balloon Atrial Septostomy) for emergency mixing. * **Definitive Surgery:** **Jatene Procedure** (Arterial Switch Operation), ideally performed within the first 2 weeks of life.
Question 4: What is the most common congenital cardiac abnormality associated with maternal rubella infection during pregnancy?
- A. Atrial septal defect
- B. Patent ductus arteriosus (Correct Answer)
- C. Ventricular septal defect
- D. Coarctation of the aorta
Explanation: **Explanation:** Congenital Rubella Syndrome (CRS) occurs due to transplacental transmission of the rubella virus, primarily during the first trimester. The virus causes vasculitis and inhibits cell division, leading to structural malformations. **Why Patent Ductus Arteriosus (PDA) is correct:** PDA is the most characteristic and common cardiac lesion in CRS. The rubella virus interferes with the normal musculature development of the ductus arteriosus and inhibits the postnatal constriction process, preventing its physiological closure. While **Peripheral Pulmonary Artery Stenosis (PPS)** is also highly specific to rubella, PDA remains the most frequently cited "most common" abnormality in standard pediatric textbooks (like Nelson) and medical examinations. **Analysis of Incorrect Options:** * **A. Atrial septal defect (ASD):** While ASD can occur in various syndromes (like Holt-Oram), it is not the primary association for rubella. * **C. Ventricular septal defect (VSD):** VSD is the most common congenital heart disease overall in the general population, but it is not specifically linked to maternal rubella. * **D. Coarctation of the aorta:** This is most classically associated with **Turner Syndrome**, not viral infections. **NEET-PG High-Yield Pearls:** * **Gregg’s Triad of CRS:** 1. Cataracts (Salt and pepper retinopathy), 2. Sensorineural deafness (most common overall finding), 3. Cardiac defects (PDA/PPS). * **"Blueberry Muffin" Rash:** Extramedullary hematopoiesis seen in neonates with CRS. * **Timing:** The risk of fetal damage is highest (up to 85%) if the mother is infected within the first 11 weeks of gestation. * **Diagnosis:** Confirmed by Rubella-specific IgM antibodies in the newborn.
Question 5: In Tetralogy of Fallot, when does the foramen ovale close?
- A. 6 months
- B. 2 years
- C. 1 year
- D. Never (Correct Answer)
Explanation: In **Tetralogy of Fallot (TOF)**, the foramen ovale typically remains patent, a condition often referred to as **Pentalogy of Fallot** when a patent foramen ovale (PFO) or atrial septal defect (ASD) is present. ### **Why the Correct Answer is "Never"** The underlying pathophysiology of TOF involves right ventricular outflow tract obstruction (RVOTO) and a large ventricular septal defect (VSD). This leads to: 1. **Increased Right-Sided Pressure:** The severe pulmonary stenosis causes high pressure in the right ventricle, which is transmitted to the right atrium. 2. **Pressure Gradient:** For the foramen ovale to close physiologically, left atrial pressure must exceed right atrial pressure. In TOF, the elevated right-sided pressures prevent this functional closure. 3. **Compensatory Mechanism:** The patency of the foramen ovale often serves as a "relief valve," allowing a right-to-left shunt at the atrial level, which may slightly improve systemic cardiac output (though at the cost of increased cyanosis). Therefore, it does not close spontaneously as it would in a normal heart. ### **Why Other Options are Incorrect** * **A, B, and C:** In a healthy neonate, the foramen ovale closes functionally at birth and anatomically within the first year of life (usually by **6 months to 1 year**). These timelines do not apply to TOF due to the persistent pressure derangements described above. ### **NEET-PG High-Yield Pearls** * **Pentalogy of Fallot:** TOF + ASD (or Patent Foramen Ovale). * **Boot-shaped heart (Coeur en sabot):** Seen on X-ray due to right ventricular hypertrophy and an upturned apex. * **The "Shunt" Rule:** The degree of cyanosis in TOF is determined primarily by the severity of **pulmonary stenosis**, not the size of the VSD. * **Squatting Position:** Increases systemic vascular resistance (SVR), which decreases the right-to-left shunt and improves oxygenation during a "Tet spell."
Question 6: In a patient of rheumatic carditis, for how long is the full dose of steroid typically given?
- A. 3 weeks
- B. 6 weeks
- C. 9 weeks
- D. 12 weeks (Correct Answer)
Explanation: **Explanation:** In the management of **Acute Rheumatic Fever (ARF)**, steroids (typically Prednisolone) are indicated for patients with **severe carditis** (evidenced by cardiomegaly, congestive heart failure, or third-degree heart block). The standard therapeutic regimen for steroids in rheumatic carditis follows a specific tapering schedule to prevent "rebound" phenomena and ensure the suppression of inflammation. The **total duration of steroid therapy is 12 weeks**. 1. **Why 12 weeks is correct:** The protocol involves giving a full dose of Prednisolone (2 mg/kg/day) for the first **2 weeks**. This is followed by a gradual tapering over the next **10 weeks**, making the total duration 12 weeks. Aspirin is often started during the last 2 weeks of the steroid taper to prevent a clinical rebound of symptoms. 2. **Why other options are incorrect:** * **3, 6, or 9 weeks** are insufficient durations. Stopping steroids prematurely in severe carditis carries a high risk of the recurrence of inflammatory markers (ESR/CRP) and clinical symptoms. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice:** Aspirin is the drug of choice for ARF with arthritis or mild carditis (without cardiomegaly). Steroids are reserved for **severe carditis**. * **Aspirin Dose:** 75–100 mg/kg/day in 4 divided doses (Anti-inflammatory dose). * **Jones Criteria:** Remember that Carditis is a **Major Criterion** and is the only component of ARF that leads to chronic valvular heart disease (most commonly Mitral Stenosis). * **Prophylaxis:** Secondary prophylaxis (Benzathine Penicillin G every 3–4 weeks) is mandatory to prevent recurrences. For carditis with residual heart disease, prophylaxis is continued for 10 years or until age 40 (sometimes lifelong).
Question 7: A 2-year-old boy presented with signs of congested cardiac failure and a right-to-left shunt. What is the most likely diagnosis?
- A. Dandy-Walker malformation
- B. Vein of Galen malformation (Correct Answer)
- C. Mega cisterna magna
- D. Crouzon syndrome
Explanation: **Explanation:** The correct answer is **Vein of Galen Malformation (VOGM)**. **Why it is correct:** Vein of Galen malformation is a rare arteriovenous malformation (AVM) where embryonic precursor vessels drain directly into the persistent median prosencephalic vein. This creates a high-flow, low-resistance shunt. In pediatrics, this massive shunting of blood from the arterial system directly into the venous system leads to: 1. **High-output Congestive Cardiac Failure (CCF):** The heart cannot keep up with the massive venous return. 2. **Right-to-Left Shunt:** The increased volume in the right heart leads to pulmonary hypertension, which can cause deoxygenated blood to shunt right-to-left across a patent foramen ovale or ductus arteriosus. **Why the other options are incorrect:** * **Dandy-Walker Malformation:** This is a posterior fossa anomaly characterized by agenesis of the cerebellar vermis and cystic dilation of the fourth ventricle. It presents with hydrocephalus and macrocephaly, not cardiac failure. * **Mega Cisterna Magna:** This is a benign enlargement of the cisterna magna with an intact cerebellar vermis. It is usually asymptomatic and an incidental finding on imaging. * **Crouzon Syndrome:** This is a craniosynostosis syndrome (premature fusion of skull bones) characterized by midface hypoplasia and proptosis. It does not cause high-output cardiac failure. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** A neonate or infant with unexplained heart failure, a cranial bruit (heard on auscultation of the skull), and prominent scalp veins. * **Imaging:** Doppler USG or MRI/MRA is the diagnostic modality of choice. * **Management:** The gold standard treatment is **endovascular embolization**. * **Key Association:** VOGM is the most common cause of high-output cardiac failure in the neonatal period due to an extracardiac shunt.
Question 8: Peripheral pulmonic stenosis is associated with which of the following conditions?
- A. William syndrome and Rubella (Correct Answer)
- B. Takayasu's arteritis
- C. Subaortic stenosis and William syndrome
- D. Subaortic stenosis and Rubella
Explanation: **Explanation:** **Peripheral Pulmonic Stenosis (PPS)** refers to the narrowing of the branches of the pulmonary artery rather than the valve itself. This condition is a classic diagnostic clue in pediatric cardiology. **Why Option A is Correct:** * **Williams Syndrome:** This is a multisystem microdeletion syndrome (7q11.23). The most characteristic cardiovascular lesion is **Supravalvular Aortic Stenosis (SVAS)**, but it is frequently associated with **Peripheral Pulmonic Stenosis** due to elastin gene mutations affecting large vessel development. * **Congenital Rubella Syndrome (CRS):** This is a classic association. While **Patent Ductus Arteriosus (PDA)** is the most common cardiac lesion in CRS, PPS is the second most common and highly characteristic finding. **Analysis of Incorrect Options:** * **Takayasu’s Arteritis (Option B):** This is a large-vessel vasculitis primarily involving the aorta and its main branches. While it can involve the pulmonary arteries in rare cases, it is not a classic association for congenital PPS. * **Subaortic Stenosis (Options C & D):** Subaortic stenosis (narrowing below the aortic valve) is typically an isolated lesion or associated with Shone’s complex. It is **not** a feature of Williams syndrome (which features *supravalvular* stenosis) or Rubella. **High-Yield Clinical Pearls for NEET-PG:** * **Williams Syndrome Triad:** "Elfin" facies, hypercalcemia (infancy), and cocktail party personality. * **Alagille Syndrome:** Another high-yield association for PPS, characterized by paucity of interlobular bile ducts (cholestasis) and butterfly vertebrae. * **Auscultation:** PPS produces a systolic murmur heard best at the upper left sternal border, often radiating to the axilla and back.
Question 9: Which of the following is considered one of Nada's major criteria for the clinical diagnosis of congenital heart disease?
- A. Systolic murmur grade I or II
- B. Diastolic murmur (Correct Answer)
- C. Abnormal blood pressure
- D. Abnormal electrocardiogram
Explanation: **Explanation:** Nada’s criteria are a set of clinical guidelines used to screen for significant heart disease in children. Diagnosis is established if a patient meets **one major criterion** or **two minor criteria**. **Why the correct answer is right:** * **Diastolic Murmur:** Any diastolic murmur in a child is considered pathological until proven otherwise. Because it almost always indicates structural heart disease (such as aortic or pulmonary regurgitation, or mitral stenosis), it is classified as a **Major Criterion**. **Analysis of incorrect options:** * **Systolic murmur grade I or II (Option A):** These are considered **Minor Criteria**. Low-grade systolic murmurs are often "innocent" or functional in children. To be a Major Criterion, a systolic murmur must be **Grade III or higher** or associated with a thrill. * **Abnormal blood pressure (Option C):** This is a **Minor Criterion**. While it may suggest conditions like coarctation of the aorta, it is not definitive enough on its own to be a major diagnostic pillar. * **Abnormal electrocardiogram (Option D):** This is a **Minor Criterion**. ECG changes can be non-specific in pediatrics; however, an abnormal chest X-ray (showing cardiomegaly or abnormal vascularity) is also a minor criterion. **Nada’s Criteria Summary Table:** | **Major Criteria** | **Minor Criteria** | | :--- | :--- | | 1. Systolic murmur ≥ Grade III | 1. Systolic murmur < Grade III | | 2. **Diastolic murmur** | 2. Abnormal ECG | | 3. Cyanosis | 3. Abnormal X-ray (Cardiomegaly/Vascularity) | | 4. Congestive Heart Failure | 4. Abnormal Blood Pressure | **NEET-PG High-Yield Pearls:** * **Diagnosis:** 1 Major OR 2 Minor criteria. * **Most common CHD:** VSD (Membranous type is most common overall). * **Most common Cyanotic CHD:** Tetralogy of Fallot (after infancy); TGA (in the neonatal period). * **Innocent Murmurs:** Usually systolic, soft (Grade I-II), and change with position (e.g., Still’s murmur).
Question 10: A baby is born with a flat facial profile, prominent epicanthal folds, and a single palmar crease. The baby vomits when fed, and upper GI studies demonstrate gas in the stomach and duodenal bulb. Which of the following cardiovascular abnormalities might this child also have?
- A. Atrial septal defect
- B. Berry aneurysm
- C. Coarctation of the aorta
- D. Endocardial cushion defect (Correct Answer)
Explanation: ### Explanation **1. Analysis of the Correct Answer (D):** The clinical presentation describes a neonate with **Down Syndrome (Trisomy 21)**, characterized by a flat facial profile, epicanthal folds, and a single palmar crease (Simian crease). The vomiting and "double bubble" appearance on imaging (gas in the stomach and duodenal bulb) indicate **Duodenal Atresia**, a classic gastrointestinal association of Down Syndrome. Approximately 40-50% of children with Down Syndrome have congenital heart disease. The most common cardiac lesion is an **Endocardial Cushion Defect** (also known as Atrioventricular Septal Defect or AVSD), accounting for nearly 40% of cases in this population. This occurs due to the failure of the superior and inferior endocardial cushions to fuse, leading to a common AV valve and defects in the atrial and ventricular septa. **2. Analysis of Incorrect Options:** * **A. Atrial Septal Defect (ASD):** While Secundum ASDs can occur in Down Syndrome, AVSD (an ostium primum defect) is significantly more specific and common in this context. * **B. Berry Aneurysm:** These are associated with **Autosomal Dominant Polycystic Kidney Disease (ADPKD)** and Ehlers-Danlos syndrome, not Down Syndrome. * **C. Coarctation of the Aorta:** This is the classic cardiovascular association for **Turner Syndrome (45, XO)**, not Trisomy 21. **3. NEET-PG High-Yield Pearls:** * **Most common cardiac defect in Down Syndrome:** AVSD (Endocardial Cushion Defect). * **Second most common cardiac defect in Down Syndrome:** Ventricular Septal Defect (VSD). * **GI Associations:** Duodenal atresia ("Double Bubble" sign), Hirschsprung disease, and Celiac disease. * **Hematologic Association:** Increased risk of ALL (Acute Lymphoblastic Leukemia) and AML (specifically M7 subtype/Megakaryoblastic).
Practice by Chapter
Congenital Heart Diseases: Cyanotic
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Congenital Heart Diseases: Acyanotic
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Myocarditis and Cardiomyopathies
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Arrhythmias in Children
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Heart Failure in Children
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Systemic Hypertension
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Cardiac Evaluation and Diagnostics
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