Cardiology — MCQs
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What is the most common organism responsible for symptomatic native valve infective endocarditis in children?
A 15-year-old boy complains of pain in his legs when he runs more than 300 m. Physical examination shows temperature, 36.8°C; pulse, 76/min; respirations, 22/min; and blood pressure, 165/90 mm Hg. The radial pulses are 4+, and the dorsalis pedis pulses are 1+. Arterial blood gas measurement shows a normal oxygen saturation level. Which of the following congenital cardiovascular anomalies is most likely to be present in this patient?
Pulmonary blood flow is increased in all of the following conditions except:
Which of the following is NOT a component of Tetralogy of Fallot?
All of the following features are seen in Kawasaki disease except?
A child presents with congenital cyanotic heart disease and polydactyly. What is the likely diagnosis?
Which of the following statements is true regarding Tetralogy of Fallot?
In Transposition of the Great Arteries (TGA), what is the relative position of the aorta to the pulmonary artery?
Which of the following syndromes is best associated with congenital heart disease?
Which of the following drug combinations is used in a patient with tetralogy of Fallot?
Cardiology Indian Medical PG Practice Questions and MCQs
Question 121: What is the most common organism responsible for symptomatic native valve infective endocarditis in children?
- A. Beta-hemolytic streptococci
- B. Alpha-hemolytic streptococci
- C. Staphylococcus aureus (Correct Answer)
- D. Group D streptococci
Explanation: **Explanation:** **Staphylococcus aureus** is currently the most common cause of symptomatic native valve infective endocarditis (IE) in children. While historically Viridans group streptococci (Alpha-hemolytic) were more prevalent, the epidemiology has shifted due to increased use of indwelling central venous catheters and more frequent cardiac interventions. *S. aureus* is highly virulent, often leading to acute, fulminant presentations with rapid valvular destruction and systemic embolization, even in children without prior structural heart disease. **Analysis of Incorrect Options:** * **Alpha-hemolytic streptococci (Viridans group):** These were previously the leading cause of IE in children, typically associated with dental procedures and underlying congenital heart disease (CHD). While still a major cause of subacute IE, they have been surpassed by *S. aureus* in overall frequency. * **Beta-hemolytic streptococci (e.g., Group A):** These are more commonly associated with Acute Rheumatic Fever (ARF) rather than direct infective endocarditis. * **Group D streptococci (e.g., S. bovis/gallolyticus):** These are rare in the pediatric population and are more typically associated with colonic pathology in adults. **High-Yield Pearls for NEET-PG:** * **Most common underlying risk factor:** Congenital Heart Disease (CHD), specifically VSD, TOF, and Left-sided obstructive lesions. * **Most common site:** Mitral valve (overall), but Tricuspid valve in cases of IV drug use or central lines. * **Duke Criteria:** The gold standard for diagnosis (requires 2 Major, 1 Major + 3 Minor, or 5 Minor criteria). * **Prophylaxis:** Indicated only for high-risk cardiac conditions (e.g., prosthetic valves, cyanotic CHD) before dental procedures involving gingival manipulation.
Question 122: A 15-year-old boy complains of pain in his legs when he runs more than 300 m. Physical examination shows temperature, 36.8°C; pulse, 76/min; respirations, 22/min; and blood pressure, 165/90 mm Hg. The radial pulses are 4+, and the dorsalis pedis pulses are 1+. Arterial blood gas measurement shows a normal oxygen saturation level. Which of the following congenital cardiovascular anomalies is most likely to be present in this patient?
- A. Aortic valve stenosis
- B. Coarctation of the aorta (Correct Answer)
- C. Patent ductus arteriosus
- D. Transposition of the great arteries
Explanation: ### Explanation The clinical presentation of upper limb hypertension (165/90 mm Hg) associated with weak lower limb pulses (1+ dorsalis pedis vs. 4+ radial) and exertional leg pain (claudication) is a classic hallmark of **Coarctation of the Aorta (CoA)**. **1. Why Coarctation of the Aorta is Correct:** CoA is a congenital narrowing of the aorta, typically occurring near the insertion of the ductus arteriosus (post-ductal in adults). This obstruction creates a pressure gradient: * **Proximal to the narrowing:** Hypertension occurs in the upper extremities and head. * **Distal to the narrowing:** Hypotension and decreased perfusion occur in the lower extremities, leading to weak pulses and **intermittent claudication** (leg pain during exercise). **2. Why the Other Options are Incorrect:** * **Aortic Valve Stenosis:** While it causes a systolic murmur and can lead to syncope or chest pain, it would result in weak pulses globally (pulsus parvus et tardus), not a differential between upper and lower limbs. * **Patent Ductus Arteriosus (PDA):** Typically presents with a continuous machinery murmur and **bounding pulses** (wide pulse pressure) due to runoff from the aorta to the pulmonary artery, not diminished lower limb pulses. * **Transposition of the Great Arteries (TGA):** This is a cyanotic heart disease usually presenting in the neonatal period with severe hypoxemia. This patient has normal oxygen saturation and is 15 years old. **3. NEET-PG High-Yield Pearls for CoA:** * **Radio-femoral delay:** The most important physical sign to check in any hypertensive young patient. * **Chest X-ray findings:** Look for the **"3" sign** (indentation of the aorta) and **rib notching** (due to collateral circulation through intercostal arteries eroding the inferior surface of the ribs). * **Association:** Strongly associated with **Turner Syndrome** (3-10% of cases) and **Bicuspid Aortic Valve** (up to 70% of cases). * **Gold Standard Diagnosis:** CT Angiography or MRI; however, Echocardiography is the initial screening tool.
Question 123: Pulmonary blood flow is increased in all of the following conditions except:
- A. Atrial septal defect (ASD)
- B. Ventricular septal defect (VSD)
- C. Tetralogy of Fallot (TOF) (Correct Answer)
- D. Transposition of great arteries (TGA)
Explanation: **Explanation:** The fundamental concept behind this question is the classification of Congenital Heart Diseases (CHD) into **Acyanotic (Left-to-Right shunts)** and **Cyanotic (Right-to-Left shunts)**, and further sub-classifying them based on pulmonary blood flow. **Why Tetralogy of Fallot (TOF) is the correct answer:** TOF is a cyanotic CHD characterized by four features: VSD, Overriding of aorta, Right Ventricular Hypertrophy, and **Pulmonary Stenosis (PS)**. The pulmonary stenosis acts as a physical obstruction to the outflow of blood from the right ventricle to the lungs. Consequently, blood is shunted right-to-left across the VSD, leading to **decreased pulmonary blood flow** and a "boot-shaped" heart with oligemic lung fields on X-ray. **Analysis of Incorrect Options:** * **ASD & VSD:** These are acyanotic CHDs with left-to-right shunting. Because pressure is higher on the left side of the heart, blood flows back into the right side and is recirculated through the lungs, leading to **increased pulmonary blood flow**. * **TGA:** Although TGA is a cyanotic CHD, it is characterized by **increased pulmonary blood flow**. In TGA, the two circulations are in parallel; the lungs receive a massive volume of blood because there is no outflow obstruction, often leading to early congestive heart failure. **NEET-PG High-Yield Pearls:** * **Cyanotic CHD with Decreased Flow:** TOF, Tricuspid Atresia, Ebstein Anomaly. * **Cyanotic CHD with Increased Flow:** TGA, TAPVC, Truncus Arteriosus, Single Ventricle. * **X-ray Findings:** TOF (Boot-shaped heart/Coeur en sabot), TGA (Egg-on-a-string appearance), TAPVC (Snowman/Figure-of-8 appearance). * **Most common cyanotic CHD:** TOF (overall), but TGA is the most common cyanotic CHD presenting in the *neonatal* period.
Question 124: Which of the following is NOT a component of Tetralogy of Fallot?
- A. Ventricular Septal Defect (VSD)
- B. Subpulmonary stenosis
- C. Right ventricular hypertrophy
- D. Patent Ductus Arteriosus (PDA) (Correct Answer)
Explanation: **Explanation:** Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease (CCHD) beyond the neonatal period. As the name "Tetralogy" suggests, it is characterized by a constellation of four specific anatomical defects resulting from the **anterosuperior deviation of the infundibular (conal) septum**. **Why PDA is the correct answer:** Patent Ductus Arteriosus (PDA) is **not** a primary component of TOF. While a PDA may be present in a neonate with TOF and is often life-saving (providing "duct-dependent" pulmonary blood flow in severe cases), it is an associated finding rather than a diagnostic criteria of the tetralogy. **Analysis of the four components (Incorrect Options):** 1. **Ventricular Septal Defect (VSD):** Typically a large, non-restrictive malalignment defect. 2. **Subpulmonary Stenosis:** Also known as infundibular stenosis. This right ventricular outflow tract obstruction (RVOTO) determines the severity of cyanosis. 3. **Right Ventricular Hypertrophy (RVH):** A secondary response to the high pressure the right ventricle must generate to overcome the RVOTO. 4. **Overriding of the Aorta:** The aorta is displaced to the right, straddling the VSD and receiving blood from both ventricles. **NEET-PG High-Yield Pearls:** * **X-ray Finding:** "Boot-shaped heart" (Coeur en sabot) due to an upturned apex (RVH) and a concave pulmonary segment. * **Clinical Feature:** **"Tet Spells"** (hypercyanotic spells) occur due to an acute increase in RVOTO. Management includes the **knee-chest position** (to increase systemic vascular resistance) and oxygen. * **Murmur:** The murmur in TOF is due to **pulmonary stenosis**, not the VSD (which is usually too large to create a murmur). * **ECG:** Shows Right Axis Deviation (RAD) and RVH.
Question 125: All of the following features are seen in Kawasaki disease except?
- A. Coronary artery aneurysms
- B. Red strawberry tongue
- C. Exudative conjunctivitis (Correct Answer)
- D. Cervical lymphadenopathy
Explanation: **Explanation:** Kawasaki Disease (KD) is an acute, febrile, medium-vessel vasculitis that primarily affects children under 5 years of age. The diagnosis is clinical, based on the presence of high-grade fever for ≥5 days plus at least 4 out of 5 classic criteria. **Why "Exudative Conjunctivitis" is the correct answer:** In Kawasaki disease, the ocular involvement is characteristically **bilateral, non-exudative conjunctival injection** (sparing the limbus). The absence of discharge or "pus" is a key clinical differentiator from viral or bacterial conjunctivitis. Therefore, the presence of exudate points away from a diagnosis of KD. **Analysis of Incorrect Options:** * **Coronary Artery Aneurysms (A):** This is the most serious complication of KD, occurring in 20-25% of untreated cases. It typically develops in the subacute phase (weeks 2–4). * **Red Strawberry Tongue (B):** This is a classic manifestation of oropharyngeal changes, which also include cracked, erythematous lips and diffuse pharyngeal hyperemia. * **Cervical Lymphadenopathy (D):** This is usually unilateral, non-fluctuant, and involves at least one node >1.5 cm in diameter. It is often the least common of the five clinical criteria. **NEET-PG High-Yield Pearls:** * **Mnemonic (CRASH and Burn):** **C**onjunctivitis (non-exudative), **R**ash (polymorphous), **A**denopathy (cervical), **S**trawberry tongue, **H**and/foot changes (edema/desquamation), and **Burn** (Fever >5 days). * **Treatment:** IVIG (2g/kg) + High-dose Aspirin. IVIG is most effective when given within the first 10 days to prevent coronary aneurysms. * **Lab Findings:** Elevated ESR/CRP, thrombocytosis (after week 1), and sterile pyuria.
Question 126: A child presents with congenital cyanotic heart disease and polydactyly. What is the likely diagnosis?
- A. Ellis-van Creveld syndrome (Correct Answer)
- B. Rubinstein-Taybi syndrome
- C. McKusick-Kaufman syndrome
- D. Edward syndrome
Explanation: **Explanation:** **Ellis-van Creveld Syndrome (Chondroectodermal Dysplasia)** is the correct diagnosis. It is a rare autosomal recessive skeletal dysplasia characterized by a classic tetrad: 1. **Chondrodystrophy:** Short-limb dwarfism. 2. **Polydactyly:** Specifically post-axial (extra finger on the pinky side). 3. **Ectodermal Dysplasia:** Affecting nails, teeth (hypodontia), and hair. 4. **Congenital Heart Disease:** Occurs in ~50-60% of cases, most commonly a **Single Atrium** or a large Atrial Septal Defect (ASD), leading to cyanosis. **Analysis of Incorrect Options:** * **Rubinstein-Taybi Syndrome:** Characterized by "broad thumbs and broad great toes," intellectual disability, and facial dysmorphism. While heart defects (VSD/PDA) occur, polydactyly is not a feature. * **McKusick-Kaufman Syndrome:** Features a triad of hydrometrocolpos (in females), polydactyly, and congenital heart disease. However, it lacks the dwarfism and ectodermal dysplasia seen in Ellis-van Creveld. * **Edward Syndrome (Trisomy 18):** Associated with "clenched fists" with overlapping fingers, rocker-bottom feet, and VSD. It typically presents with micrognathia and low-set ears rather than isolated polydactyly and dwarfism. **High-Yield Clinical Pearls for NEET-PG:** * **Single Atrium** is the "pathognomonic" cardiac lesion for Ellis-van Creveld syndrome. * The syndrome is highly prevalent in the **Old Order Amish** population (founder effect). * **Post-axial polydactyly** is the most consistent feature (present in nearly 100% of cases). * Differential for Polydactyly + Heart Disease: Patau Syndrome (Trisomy 13), Holt-Oram (rarely), and Bardet-Biedl Syndrome.
Question 127: Which of the following statements is true regarding Tetralogy of Fallot?
- A. Cyanosis is often present in the first few days of life.
- B. There is a right-sided aortic arch in about 50% of cases.
- C. The murmur becomes softer during a cyanotic spell as flow through the pulmonary valve is increased.
- D. There is an association with DiGeorge syndrome. (Correct Answer)
Explanation: **Explanation:** **Tetralogy of Fallot (TOF)** is the most common cyanotic congenital heart disease (CHD) beyond infancy. It consists of four components: VSD, overriding of the aorta, pulmonary stenosis (infundibular), and right ventricular hypertrophy. **Why Option D is Correct:** TOF is strongly associated with chromosomal microdeletions, most notably **22q11.2 deletion (DiGeorge syndrome)**. Approximately 15-25% of TOF patients have this deletion. DiGeorge syndrome presents with the "CATCH-22" mnemonic: Cardiac defects (TOF/Truncus), Abnormal facies, Thymic hypoplasia (T-cell deficiency), Cleft palate, and Hypocalcemia. **Analysis of Incorrect Options:** * **Option A:** Cyanosis in TOF is typically **not present at birth**. It usually appears between 3–6 months of age as the infundibular stenosis progresses. If a neonate is cyanotic on day one, think of Transposition of the Great Arteries (TGA). * **Option B:** A **right-sided aortic arch** is seen in approximately **25%** of TOF cases, not 50%. While high-yield, 50% is an overestimation. * **Option C:** During a "Tet spell" (cyanotic spell), the murmur actually becomes **softer or disappears**. This is because the spell is caused by an acute increase in right-to-left shunting due to near-total obstruction of the right ventricular outflow tract (RVOT); thus, flow across the pulmonary valve **decreases**. **High-Yield Clinical Pearls for NEET-PG:** * **X-ray finding:** "Boot-shaped heart" (Coeur en sabot) due to an upturned apex (RVH) and concave pulmonary segment. * **ECG:** Shows Right Axis Deviation and RVH. * **Management of Tet Spell:** Knee-chest position (increases systemic vascular resistance), Oxygen, Morphine, and Beta-blockers (Propranolol). * **Most important prognostic factor:** The severity of pulmonary stenosis.
Question 128: In Transposition of the Great Arteries (TGA), what is the relative position of the aorta to the pulmonary artery?
- A. Posterior and left to the pulmonary artery
- B. Posterior and right to the pulmonary artery
- C. Anterior and left to the pulmonary artery
- D. Anterior and right to the pulmonary artery (Correct Answer)
Explanation: **Explanation:** In **Transposition of the Great Arteries (TGA)**, specifically the most common form known as **d-TGA** (dextro-TGA), the embryological defect lies in the failure of the conotruncal septum to spiral. Instead of the normal spiral development, the septum grows straight. This results in the aorta arising from the morphological right ventricle and the pulmonary artery arising from the morphological left ventricle. **Why Option D is correct:** In d-TGA, the aorta is displaced **anteriorly** and typically to the **right** of the pulmonary artery. This spatial relationship is a hallmark of the condition and is easily visualized on an echocardiogram or CT scan. **Analysis of Incorrect Options:** * **Options A & B (Posterior):** In a normal heart, the aorta is posterior and to the right of the pulmonary artery. Therefore, any "posterior" position of the aorta is characteristic of normal anatomy, not TGA. * **Option C (Anterior and left):** This describes **l-TGA** (levo-TGA or Congenitally Corrected TGA), where the ventricles are also switched (ventricular inversion). While the aorta is anterior, it lies to the left of the pulmonary artery. **High-Yield Clinical Pearls for NEET-PG:** * **Chest X-ray Finding:** The narrow vascular pedicle and globular heart shape create the classic **"Egg-on-a-string"** appearance. * **Survival:** TGA is an **incompatible-with-life** cyanotic heart disease unless there is a shunting lesion (PDA, VSD, or ASD) to allow mixing of the parallel circulations. * **Management:** The initial medical management is **PGE1 infusion** to keep the ductus arteriosus open. The definitive surgical treatment of choice is the **Arterial Switch Operation (Jatene Procedure)**, ideally performed in the first 2 weeks of life.
Question 129: Which of the following syndromes is best associated with congenital heart disease?
- A. Lesch-Nyhan syndrome
- B. Rasmussen syndrome
- C. Holt Oram syndrome (Correct Answer)
- D. LEOPARD syndrome
Explanation: **Explanation:** **Holt-Oram Syndrome (Correct Answer):** Also known as **Heart-Hand Syndrome**, this is an autosomal dominant condition caused by a mutation in the **TBX5 gene**. It is characterized by the co-occurrence of upper limb deformities (most commonly a triphalangeal or absent thumb and radial dysplasia) and congenital heart defects. The most frequent cardiac association is an **Atrial Septal Defect (ASD)** of the ostium secundum type, followed by Ventricular Septal Defects (VSD). **Analysis of Incorrect Options:** * **Lesch-Nyhan Syndrome:** An X-linked recessive disorder caused by a deficiency of the enzyme HGPRT. It presents with hyperuricemia, gout, and characteristic self-mutilating behavior, but is not typically associated with structural heart disease. * **Rasmussen Syndrome:** A rare, progressive neurological inflammatory disease (chronic focal encephalitis) characterized by intractable seizures and hemiparesis. It has no cardiac involvement. * **LEOPARD Syndrome:** Now often referred to as **Noonan Syndrome with Multiple Lentigines**. While it *does* involve the heart (most commonly hypertrophic cardiomyopathy or pulmonary stenosis), Holt-Oram is the "classic" textbook association for a syndrome defined by the heart-limb axis in NEET-PG contexts. **Clinical Pearls for NEET-PG:** * **Holt-Oram:** Remember the "Hand-Heart" link. If a question mentions a "thumb deformity + murmur," think Holt-Oram. * **TBX5 Gene:** High-yield genetic association. * **ASD:** The most common cardiac lesion in this syndrome (specifically Secundum type). * **LEOPARD Mnemonic:** **L**entigines, **E**CG conduction defects, **O**cular hypertelorism, **P**ulmonary stenosis, **A**bnormal genitalia, **R**etardation of growth, and **D**eafness.
Question 130: Which of the following drug combinations is used in a patient with tetralogy of Fallot?
- A. Digoxin, furosemide, and oxygen
- B. Morphine, sodium bicarbonate, and propranolol (Correct Answer)
- C. Atenolol with direct current cardioversion
- D. Captopril with aminophylline
Explanation: In Tetralogy of Fallot (TOF), the primary acute emergency is a **Hypercyanotic Spell (Tet Spell)**. This occurs due to an acute increase in right-to-left shunting across the VSD, triggered by an imbalance between pulmonary and systemic vascular resistance. ### Why Option B is Correct: The management of a Tet spell focuses on increasing systemic vascular resistance (SVR) and decreasing pulmonary vascular resistance (PVR): * **Morphine:** It suppresses the respiratory center (reducing hyperpnea) and has a sedative effect that decreases catecholamine surge, thereby reducing infundibular spasm. * **Sodium Bicarbonate:** Corrects metabolic acidosis resulting from prolonged hypoxia. Acidosis is a potent pulmonary vasoconstrictor; correcting it helps lower PVR. * **Propranolol:** A beta-blocker that relaxes the infundibular spasm (improving pulmonary blood flow) and slows the heart rate, allowing better ventricular filling. ### Why Other Options are Incorrect: * **Option A:** Digoxin and Furosemide are used for **congestive heart failure (CHF)**. TOF is a "cyanotic heart disease with decreased pulmonary blood flow"; the right ventricle is not in failure because the VSD acts as a pressure-release valve. * **Option B & D:** Atenolol, DC cardioversion, Captopril (ACE inhibitor), and Aminophylline have no role in the acute management of right-to-left shunts or infundibular spasms. ACE inhibitors can actually worsen the shunt by decreasing SVR. ### High-Yield Pearls for NEET-PG: * **First-line management:** Knee-chest position (increases SVR by kinking femoral arteries). * **Drug of choice for prevention of spells:** Oral Propranolol. * **Classic X-ray finding:** Coeur-en-sabot (Boot-shaped heart) due to RV hypertrophy and upturned apex. * **Murmur:** The murmur in TOF is due to **Pulmonary Stenosis**, not the VSD. During a Tet spell, this murmur **disappears or softens** because less blood is crossing the pulmonary valve.
Practice by Chapter
Congenital Heart Diseases: Cyanotic
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Congenital Heart Diseases: Acyanotic
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Rheumatic Heart Disease
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Kawasaki Disease
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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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