Cardiology — MCQs
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What is the most appropriate management for maintaining patency of the ductus arteriosus in a neonate?
Physical examination of a neonate is remarkable for a holosystolic murmur. There is no cyanosis. Echocardiography demonstrates an ostium primum defect in the lower part of the interatrial septum that is accompanied by malformations of the adjacent atrioventricular valves. These lesions are most likely associated with which of the following disorders?
Which cardiac abnormality is commonly seen in Noonan's syndrome?
During cardiac examination of a newborn infant, a murmur is detected, and the diagnosis of patent ductus arteriosus is made. Which of the following best describes the direction of blood flow through the patent ductus arteriosus in this infant?
Which of the following is a true statement about Rheumatic fever in children?
What are the major criteria for the diagnosis of rheumatic fever?
Coarctation of the aorta may be associated with all of the following except:
Congestive heart failure is seen in all of the following congenital heart defects except?
In transposition of great vessels, all of the following are true except?
Which of the following is NOT a component of Kawasaki disease?
Cardiology Indian Medical PG Practice Questions and MCQs
Question 91: What is the most appropriate management for maintaining patency of the ductus arteriosus in a neonate?
- A. Prostaglandin E1 (Correct Answer)
- B. Oxygen
- C. Nitric oxide
- D. Indomethacin
Explanation: **Explanation:** In neonates with ductal-dependent congenital heart diseases (such as Transposition of the Great Arteries, Hypoplastic Left Heart Syndrome, or Pulmonary Atresia), maintaining the patency of the **Ductus Arteriosus (DA)** is life-saving to ensure systemic or pulmonary blood flow. **Correct Option: A. Prostaglandin E1 (Alprostadil)** Prostaglandin E1 (PGE1) is a potent vasodilator that acts directly on the smooth muscle of the ductus arteriosus to prevent its physiological closure. It is the gold-standard treatment for maintaining ductal patency until definitive surgical intervention can be performed. **Why Incorrect Options are Wrong:** * **B. Oxygen:** Oxygen is a potent **constrictor** of the ductus arteriosus. High concentrations of oxygen after birth trigger the closure of the DA by decreasing pulmonary vascular resistance and inhibiting local prostaglandin production. * **C. Nitric Oxide:** This is a selective pulmonary vasodilator used to treat Persistent Pulmonary Hypertension of the Newborn (PPHN). It does not have a primary role in maintaining ductal patency. * **D. Indomethacin:** This is a non-selective COX inhibitor that inhibits prostaglandin synthesis. It is used to **close** a Patent Ductus Arteriosus (PDA) in premature infants, the exact opposite of the goal in this question. **High-Yield Clinical Pearls for NEET-PG:** * **Side Effect of PGE1:** The most critical side effect to monitor during PGE1 infusion is **apnea**; always be prepared for endotracheal intubation. * **Closure of DA:** Functional closure occurs within 10–15 hours of birth; anatomical closure occurs by 2–3 weeks (forming the *ligamentum arteriosum*). * **Drug of Choice for PDA Closure:** IV Indomethacin or Ibuprofen (Ibuprofen is often preferred due to fewer renal side effects). Paracetamol is a newer alternative.
Question 92: Physical examination of a neonate is remarkable for a holosystolic murmur. There is no cyanosis. Echocardiography demonstrates an ostium primum defect in the lower part of the interatrial septum that is accompanied by malformations of the adjacent atrioventricular valves. These lesions are most likely associated with which of the following disorders?
- A. Cystic fibrosis
- B. Down syndrome (Correct Answer)
- C. Gaucher disease
- D. Marfan syndrome
Explanation: ### Explanation The clinical presentation describes an **Atrioventricular Septal Defect (AVSD)**, also known as an endocardial cushion defect. The combination of an **ostium primum** atrial septal defect (ASD) and malformations of the atrioventricular valves (mitral and tricuspid) is the hallmark of this condition. **1. Why Down Syndrome is Correct:** Down syndrome (Trisomy 21) is the most common chromosomal anomaly associated with congenital heart disease (CHD). Approximately 40–50% of children with Down syndrome have CHD, and of these, **AVSD is the most characteristic lesion** (occurring in nearly 40% of affected cases). The holosystolic murmur in this neonate likely results from a ventricular septal component or mitral regurgitation due to a cleft in the anterior mitral leaflet, which often accompanies primum ASDs. **2. Why Other Options are Incorrect:** * **Cystic Fibrosis:** Primarily affects the respiratory and gastrointestinal systems (thick secretions, pancreatic insufficiency). It is not typically associated with structural congenital heart defects. * **Gaucher Disease:** A lysosomal storage disorder characterized by hepatosplenomegaly and bone involvement, but not specific cardiac septal defects. * **Marfan Syndrome:** Associated with connective tissue defects leading to **Mitral Valve Prolapse (MVP)** and **Aortic Root Dilation/Dissection**, rather than endocardial cushion defects. **Clinical Pearls for NEET-PG:** * **Most common CHD in Down Syndrome:** AVSD (Endocardial Cushion Defect). * **Most common CHD overall in Down Syndrome (Indian context/some studies):** VSD is frequently cited, but AVSD remains the most *pathognomonic*. * **ECG Finding in AVSD:** Characterized by **Left Axis Deviation** (Superior axis) and a "Goose-neck deformity" on angiography. * **Ostium Primum vs. Secundum:** Primum ASDs are located in the lower part of the septum (near valves), while Secundum ASDs (most common type overall) are in the center.
Question 93: Which cardiac abnormality is commonly seen in Noonan's syndrome?
- A. Ventricular Septal Defect (VSD)
- B. Atrial Septal Defect (ASD)
- C. Pulmonary stenosis (Correct Answer)
- D. Coarctation of aorta
Explanation: **Explanation:** Noonan’s syndrome is an autosomal dominant multisystem disorder often referred to as the "male version of Turner syndrome" due to shared clinical features like short stature, webbed neck, and cubitus valgus. However, their cardiac profiles differ significantly. **Why Pulmonary Stenosis is Correct:** The most common cardiac anomaly in Noonan’s syndrome is **Pulmonary Valve Stenosis (PVS)**, occurring in approximately 50-60% of cases. It is often characterized by a **dysplastic pulmonary valve**, where the valve leaflets are thickened and redundant rather than just fused. The second most common cardiac finding is **Hypertrophic Cardiomyopathy (HCM)**, specifically asymmetric septal hypertrophy. **Analysis of Incorrect Options:** * **A. Ventricular Septal Defect (VSD):** While VSD can occur in Noonan’s, it is not the hallmark or most frequent lesion. VSD is more classically the most common congenital heart disease (CHD) overall. * **B. Atrial Septal Defect (ASD):** ASD is seen in about 6-10% of Noonan patients, often occurring in association with pulmonary stenosis, but it is not the primary diagnostic association. * **D. Coarctation of Aorta:** This is the classic cardiac association for **Turner Syndrome (45, XO)**, not Noonan’s syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Genetic Mutation:** Most commonly associated with mutations in the **PTPN11 gene** (RASopathy). * **Cardiac Profile:** Pulmonary Stenosis (50%) > HCM (20%) > ASD (10%). * **ECG Finding:** A characteristic "Left Axis Deviation" in the presence of right ventricular hypertrophy (due to PS) is a strong diagnostic clue for Noonan’s. * **Differentiating from Turner:** Noonan’s affects both males and females, has a normal karyotype, and presents with Right-sided heart lesions (PS), whereas Turner involves only females and Left-sided lesions (Bicuspid aortic valve, Coarctation).
Question 94: During cardiac examination of a newborn infant, a murmur is detected, and the diagnosis of patent ductus arteriosus is made. Which of the following best describes the direction of blood flow through the patent ductus arteriosus in this infant?
- A. From aorta to left pulmonary artery (Correct Answer)
- B. From aorta to left pulmonary vein
- C. From aorta to right pulmonary artery
- D. From left pulmonary artery to aorta
Explanation: ### Explanation **1. Why Option A is Correct:** The Patent Ductus Arteriosus (PDA) is a persistent fetal communication between the **proximal left pulmonary artery** and the **descending aorta** (just distal to the origin of the left subclavian artery). In fetal life, blood flows from the pulmonary artery to the aorta due to high pulmonary vascular resistance (PVR). However, after birth, PVR drops significantly while systemic vascular resistance (SVR) increases. Consequently, the pressure in the aorta becomes much higher than in the pulmonary artery. This pressure gradient causes blood to flow from the **high-pressure aorta to the low-pressure left pulmonary artery** (Left-to-Right shunt) throughout both systole and diastole. **2. Why Other Options are Incorrect:** * **Option B:** The ductus arteriosus connects the arterial systems (Aorta and Pulmonary Artery). It does not involve the pulmonary veins, which carry oxygenated blood to the left atrium. * **Option C:** Anatomically, the ductus arteriosus arises from the **left** pulmonary artery (near the bifurcation of the main pulmonary artery). While the blood eventually reaches both lungs, the direct anatomical connection is to the left side. * **Option D:** This describes the **fetal** circulation pattern or a "reversed shunt" (Eisenmenger syndrome). In a standard newborn with PDA, the flow is Aorta-to-Pulmonary Artery. **3. High-Yield Clinical Pearls for NEET-PG:** * **Murmur:** Classically described as a **"Gibson Murmur"** (Continuous, machinery-type murmur) best heard at the left infraclavicular area. * **Pulse:** Characterized by **bounding pulses** and a **wide pulse pressure** due to diastolic runoff into the pulmonary circulation. * **Management:** * **Medical:** Indomethacin or Ibuprofen (NSAIDs) are used to close a PDA in preterm infants (they inhibit Prostaglandin E2). * **Maintenance:** Alprostadil (PGE1) is used to keep the ductus open in duct-dependent cyanotic heart diseases. * **Association:** Strongly associated with **Congenital Rubella Syndrome** and prematurity.
Question 95: Which of the following is a true statement about Rheumatic fever in children?
- A. Polyarthritis (Correct Answer)
- B. Caused by hemolytic streptococci
- C. Erythema marginatum is the most common manifestation
- D. All of the above
Explanation: Acute Rheumatic Fever (ARF) is a non-suppurative sequela of a Group A Streptococcal (GAS) pharyngeal infection. Diagnosis is based on the **Revised Jones Criteria**. **Explanation of Options:** * **A. Polyarthritis (Correct):** Migratory polyarthritis is the **most common major manifestation** of ARF, occurring in approximately 75% of patients. It typically involves large joints (knees, ankles, elbows, wrists) in an asymmetrical, "migratory" pattern, where one joint inflames as another subsides. It is exquisitely responsive to salicylates (aspirin). * **B. Caused by hemolytic streptococci (Incorrect):** While ARF is caused by streptococci, the statement is too vague. It is specifically caused by **Group A Beta-hemolytic Streptococci (GABHS)**. Other hemolytic streptococci (like Group B or Alpha-hemolytic) do not cause ARF. * **C. Erythema marginatum is the most common manifestation (Incorrect):** Erythema marginatum is a major criterion but is actually the **least common** manifestation, occurring in <3% of cases. **High-Yield Clinical Pearls for NEET-PG:** 1. **Jones Criteria (Major):** **J**oints (Polyarthritis), **O** (Carditis - "O" for heart shape), **N**odules (Subcutaneous), **E**rythema marginatum, **S**ydenham chorea. 2. **Carditis:** The only manifestation of ARF that can lead to permanent disability (Chronic Rheumatic Heart Disease), most commonly affecting the **Mitral Valve**. 3. **Sydenham Chorea:** Also known as St. Vitus' dance; it has the longest latent period (months) and may occur as an isolated finding. 4. **Prophylaxis:** Penicillin G benzathine is the drug of choice for secondary prevention to prevent recurrent attacks.
Question 96: What are the major criteria for the diagnosis of rheumatic fever?
- A. Erythema migrans
- B. Arthralgia
- C. Fever
- D. Subcutaneous nodules (Correct Answer)
Explanation: The diagnosis of **Acute Rheumatic Fever (ARF)** is based on the **Revised Jones Criteria (2015)**. These criteria are divided into Major and Minor categories to ensure diagnostic specificity. ### Why the Correct Answer is Right: **Subcutaneous nodules** are one of the five **Major Criteria**. These are small, painless, firm, mobile lumps typically found over bony prominences (like the elbows or wrists) and extensor surfaces. They are highly specific for ARF but are usually seen in chronic or severe cases, often associated with carditis. ### Why the Other Options are Wrong: * **A. Erythema migrans:** This is the characteristic skin rash of **Lyme Disease**. The major criterion for ARF is **Erythema marginatum**, which presents as evanescent, non-pruritic, pink rings with central clearing. * **B. Arthralgia:** This is a **Minor Criterion**. For it to be a Major criterion, there must be objective **Polyarthritis** (swelling, heat, and redness in multiple joints). Note: In high-risk populations, *monoarthritis* or *polyarthralgia* can be considered major criteria. * **C. Fever:** This is a **Minor Criterion**. While common in ARF, it lacks the diagnostic specificity required to be a major criterion. ### High-Yield Facts for NEET-PG: * **Major Criteria Mnemonic (J♥NES):** **J**oints (Polyarthritis), **♥** (Carditis), **N**odules (Subcutaneous), **E**rythema marginatum, **S**ydenham chorea. * **Essential Requirement:** Evidence of a preceding Group A Streptococcal (GAS) infection (e.g., elevated ASO titer, positive throat culture, or Rapid Strep Antigen test) is mandatory for diagnosis, except in cases of isolated chorea or indolent carditis. * **Diagnosis:** 2 Major OR 1 Major + 2 Minor criteria + Evidence of GAS infection. * **Most common manifestation:** Polyarthritis. * **Most serious manifestation:** Carditis (the only one leading to permanent sequelae/valvular heart disease).
Question 97: Coarctation of the aorta may be associated with all of the following except:
- A. Bicuspid aortic valve
- B. Turner's syndrome
- C. Renal artery stenosis (Correct Answer)
- D. Patent ductus arteriosus
Explanation: **Explanation:** Coarctation of the aorta (CoA) is a localized narrowing of the aortic lumen, typically occurring near the insertion of the ductus arteriosus (juxtaductal). **Why Renal Artery Stenosis is the Correct Answer:** Renal artery stenosis is **not** a classic association of Coarctation of the aorta. While both conditions cause secondary hypertension, they are distinct pathological entities. In CoA, hypertension in the upper extremities occurs due to mechanical obstruction and the subsequent activation of the Renin-Angiotensin-Aldosterone System (RAAS) because of decreased renal perfusion pressure. Renal artery stenosis involves narrowing of the renal arteries themselves, not the aorta. **Analysis of Incorrect Options:** * **Bicuspid Aortic Valve (BAV):** This is the **most common** cardiac anomaly associated with CoA, occurring in up to 50-85% of cases. * **Turner’s Syndrome (45, XO):** CoA is the most characteristic cardiovascular malformation in Turner’s syndrome (found in ~15-20% of patients). * **Patent Ductus Arteriosus (PDA):** CoA is frequently associated with other left-sided obstructive lesions and shunts, including PDA and Ventricular Septal Defect (VSD). **High-Yield Clinical Pearls for NEET-PG:** * **Physical Exam:** Look for "Radio-femoral delay" and a blood pressure gradient between upper and lower limbs. * **Chest X-ray:** "Rib notching" (due to collateral circulation through intercostal arteries) and the "3 sign" (pre- and post-stenotic dilatation). * **Associations:** Often part of **Shone’s Complex** (multiple left-sided obstructive lesions). * **Complications:** Berry aneurysms (Circle of Willis) are associated with CoA, increasing the risk of subarachnoid hemorrhage.
Question 98: Congestive heart failure is seen in all of the following congenital heart defects except?
- A. Transposition of the great arteries with VSD (TAPVC)
- B. Tetralogy of Fallot (TOF) (Correct Answer)
- C. Coarctation of the aorta
- D. Patent ductus arteriosus (PDA)
Explanation: **Explanation:** The core concept in pediatric cardiology regarding Congestive Heart Failure (CHF) is that it is caused by **volume overload** (left-to-right shunts) or **pressure overload** (obstructive lesions). **Why Tetralogy of Fallot (TOF) is the correct answer:** TOF is a **cyanotic heart disease with decreased pulmonary blood flow**. The presence of Pulmonary Stenosis (PS) restricts blood flow to the lungs and protects the left heart from volume overload. Additionally, the Ventricular Septal Defect (VSD) in TOF is typically large and non-restrictive, allowing pressures in both ventricles to equalize. Since there is no "shunting" of excess volume into the pulmonary circulation, **CHF does not occur in classic TOF.** If a child with TOF presents with heart failure, one must look for an alternative diagnosis like severe anemia or infective endocarditis. **Analysis of Incorrect Options:** * **PDA:** This is a left-to-right shunt. Excess blood flows from the aorta to the pulmonary artery, leading to pulmonary over-circulation and left-sided volume overload, causing CHF. * **Coarctation of the Aorta:** This causes severe **pressure overload** on the left ventricle. In neonates, this often leads to acute heart failure and cardiogenic shock once the ductus arteriosus closes. * **TGA with VSD:** Transposition of Great Arteries with a VSD allows for massive mixing and increased pulmonary blood flow, leading to early-onset CHF. **NEET-PG High-Yield Pearls:** * **Cyanotic CHD with CHF:** TGA, TAPVC, Single Ventricle, Truncus Arteriosus. * **Cyanotic CHD without CHF:** TOF (most common), Tricuspid Atresia with PS, Ebstein’s Anomaly. * **Acyanotic CHD with CHF:** Large VSD, PDA, AV Canal defects. * **Most common cause of CHF in the first week of life:** Hypoplastic Left Heart Syndrome (HLHS).
Question 99: In transposition of great vessels, all of the following are true except?
- A. Aorta arises from the right ventricle (Correct Answer)
- B. Mitral valve is continuous with the aortic valve
- C. Causes jaundice immediately after birth
- D. None of the above
Explanation: In **Transposition of the Great Arteries (TGA)**, there is ventriculoarterial discordance where the aorta arises from the right ventricle (RV) and the pulmonary artery arises from the left ventricle (LV). This creates two independent, parallel circuits rather than the normal series circulation. **Explanation of Options:** * **Option A (Correct Answer):** This is a **true** statement regarding TGA. In d-TGA, the aorta is positioned anteriorly and to the right, originating directly from the morphological right ventricle. Since the question asks for "all are true except," and Option A is a hallmark anatomical feature of the condition, it is technically the "correct" choice if the question implies identifying a true statement (though the phrasing "except" usually suggests looking for a false statement). *Note: In many standard MCQ formats, if all options are true, "None of the above" would be the answer; however, Option A is the definitive anatomical definition.* * **Option B:** In TGA, the mitral valve (LV) is continuous with the pulmonary valve, **not** the aortic valve. In a normal heart, the mitral valve is continuous with the aortic valve. Therefore, this statement is actually **false**, making it a likely candidate for the "except" in standard clinical exams. * **Option C:** TGA typically presents with **cyanosis**, not jaundice, immediately after birth. Jaundice is not a primary feature of cyanotic heart disease. **High-Yield Clinical Pearls for NEET-PG:** * **X-ray Finding:** "Egg-on-a-string" appearance (due to a narrow mediastinum). * **Survival:** Depends on mixing of blood via PDA, ASD, or VSD. * **Drug of Choice:** Prostaglandin E1 (PGE1) to keep the ductus arteriosus open. * **Procedure of Choice:** Arterial Switch Operation (Jatene procedure). * **Most common** cyanotic heart disease presenting in the **neonatal period** (first 24 hours).
Question 100: Which of the following is NOT a component of Kawasaki disease?
- A. Purulent conjunctivitis (Correct Answer)
- B. Pedal edema
- C. Truncal rash
- D. Pharyngeal congestion
Explanation: **Explanation:** Kawasaki Disease (KD) is an acute, self-limiting systemic medium-vessel vasculitis. The diagnosis is clinical, based on the presence of high-grade fever for at least 5 days plus 4 out of 5 principal criteria. **Why "Purulent Conjunctivitis" is the correct answer:** The hallmark ocular finding in Kawasaki disease is **bilateral non-exudative (bulbar) conjunctival injection**. It is typically painless and, crucially, **spares the limbus** (the area around the iris). The presence of pus or discharge (purulent conjunctivitis) points away from KD and suggests a viral or bacterial etiology. **Analysis of Incorrect Options:** * **Pedal Edema:** This is a classic component of the "Extremity Changes" criterion. In the acute phase, patients present with erythema and painful edema of the hands and feet. (In the subacute phase, periungual desquamation occurs). * **Truncal Rash:** A polymorphous exanthema (usually maculopapular or morbilliform) that primarily involves the trunk and extremities is a core diagnostic criterion. * **Pharyngeal Congestion:** This falls under "Oropharyngeal Changes," which include erythema of the pharynx, "strawberry tongue," and cracked, erythematous lips. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic (CRASH and Burn):** **C**onjunctivitis (non-purulent), **R**ash, **A**denopathy (cervical, >1.5cm, usually unilateral), **S**trawberry tongue, **H**ands/feet (edema/erythema), and **Burn** (Fever >5 days). * **Most Common Complication:** Coronary artery aneurysms (occurs in 20-25% of untreated cases). * **Treatment:** High-dose IVIG (2g/kg) plus Aspirin. This is one of the few pediatric conditions where Aspirin is indicated despite the risk of Reye syndrome. * **Echocardiography:** Should be performed at diagnosis, at 2 weeks, and at 6-8 weeks to monitor for coronary involvement.
Practice by Chapter
Congenital Heart Diseases: Cyanotic
Practice Questions
Congenital Heart Diseases: Acyanotic
Practice Questions
Rheumatic Heart Disease
Practice Questions
Kawasaki Disease
Practice Questions
Infective Endocarditis
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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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Pulmonary Hypertension
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Systemic Hypertension
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Dyslipidemia in Children
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Cardiac Evaluation and Diagnostics
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