Cardiology Practice Questions

Q: In Tetralogy of Fallot, when does the foramen ovale close?

Never. 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."

Q: In a patient of rheumatic carditis, for how long is the full dose of steroid typically given?

12 weeks. **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).

Q: 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?

Endocardial cushion defect. ### 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).

Q: Which one of the following is not included as a major criterion in the Jones criteria?

Elevated ESR. The **Jones Criteria** (revised by the AHA) are used to diagnose the first episode of **Acute Rheumatic Fever (ARF)**, which occurs as a non-suppurative sequela of Group A Streptococcal pharyngitis. ### Why Elevated ESR is the Correct Answer **Elevated ESR** (Erythrocyte Sedimentation Rate) is a **Minor Criterion**, not a major one. Minor criteria represent non-specific systemic signs of inflammation or laboratory findings. These include: * **Clinical:** Arthralgia, Fever ($\geq 38.5^\circ C$). * **Laboratory:** Elevated Acute Phase Reactants (ESR $\geq 60$ mm/hr or CRP $\geq 3.0$ mg/dL). * **ECG:** Prolonged PR interval (unless carditis is a major criterion). ### Why the Other Options are Incorrect Options A, B, and C are all **Major Criteria**, which are more specific clinical manifestations of ARF. The mnemonic **J♥NES** is commonly used: * **J - Joint Involvement (Arthritis):** Specifically migratory polyarthritis (Option B). * **♥ - Carditis:** Can manifest as pancarditis (Option A), involving the endocardium, myocardium, and pericardium. * **N - Nodules:** Subcutaneous nodules (Option C), which are firm and painless. * **E - Erythema Marginatum:** A characteristic pink, evanescent, non-pruritic rash. * **S - Sydenham Chorea:** Purposeless, involuntary movements (St. Vitus' Dance). ### NEET-PG High-Yield Pearls * **Diagnosis Requirement:** 2 Major OR 1 Major + 2 Minor criteria, PLUS evidence of preceding GAS infection (Positive throat culture, Rapid Antigen test, or Elevated/Rising ASO titer). * **Exception:** Sydenham chorea or indolent carditis can diagnose ARF without evidence of preceding infection. * **Most Common Manifestation:** Arthritis (75%). * **Most Serious Manifestation:** Carditis (can lead to chronic Rheumatic Heart Disease, most commonly affecting the **Mitral Valve**).

Q: A two-month-old infant presents with marked respiratory distress, cyanosis, and bilateral crepitations. The infant's heart rate is 180/min, respiratory rate is 56/min, and the liver span is 7.5 cm. The child has had repeated episodes of fever, cough, and respiratory distress since birth. Cardiovascular examination reveals a grade III ejection systolic murmur in the left parasternal area. Chest X-ray shows cardiomegaly with a narrow base and plethoric lung fields. What is the most likely diagnosis?

Transposition of great arteries. **Explanation:** The clinical presentation points toward a **cyanotic congenital heart disease (CCHD)** with **increased pulmonary blood flow**. **1. Why Transposition of the Great Arteries (TGA) is correct:** * **Clinical Triad:** The infant presents with early-onset cyanosis, congestive heart failure (CHF) symptoms (respiratory distress, crepitations, hepatomegaly), and recurrent respiratory infections. * **Radiology:** The "narrow base" (due to the anteroposterior alignment of the great vessels) and "cardiomegaly" create the classic **"Egg-on-a-string" appearance**, which is pathognomonic for TGA. * **Hemodynamics:** Unlike Tetralogy of Fallot, TGA presents with **plethoric lung fields** (increased pulmonary vascularity) because the pulmonary and systemic circulations are in parallel. The ejection systolic murmur is often due to associated defects like VSD or ASD, which are necessary for survival. **2. Why the other options are incorrect:** * **Tetralogy of Fallot (TOF):** While it causes cyanosis, it typically presents with **decreased** pulmonary blood flow (oligemic lung fields) and a "boot-shaped heart." CHF is rare in TOF. * **Congenital Methemoglobinemia:** Presents with "chocolate-colored" cyanosis that does not improve with oxygen, but it does not cause cardiomegaly, murmurs, or plethoric lung fields. * **Cystic Fibrosis:** Primarily a pulmonary/gastrointestinal disease. While it causes respiratory distress and cough, it would not explain a grade III murmur or the specific "narrow base" cardiac silhouette. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cyanotic heart disease at birth:** TGA. * **Most common cyanotic heart disease after 1 year of age:** TOF. * **X-ray Sign:** Egg-on-a-string (TGA). * **Management:** Prostaglandin E1 (to keep the ductus open) followed by the **Arterial Switch Operation (Jatene procedure)**, ideally performed in the first 2 weeks of life.

Q: Which of the following statements is true regarding the major criteria for Jones in acute rheumatic fever?

Sydenham chorea is a late manifestation.. ### Explanation The **Jones Criteria** (revised by AHA) are the cornerstone for diagnosing Acute Rheumatic Fever (ARF). Understanding the temporal sequence and characteristics of these major manifestations is crucial for NEET-PG. **1. Why Option B is Correct:** **Sydenham Chorea** (St. Vitus' Dance) is characterized by involuntary, purposeless movements and emotional lability. It has a long latent period (1–6 months) after the initial Group A Streptococcal infection. Consequently, it is a **late manifestation** and often appears when other signs like arthritis or elevated ESR/CRP have subsided. **2. Why Other Options are Incorrect:** * **Option A:** **Migratory Polyarthritis** is the **earliest** and most common clinical manifestation (seen in ~75% of cases). Carditis usually appears within the first 3 weeks but is not the earliest. * **Option C:** ARF characteristically involves **large joints** (knees, ankles, elbows, wrists) in a migratory pattern. Small joint involvement is rare and more suggestive of conditions like Rheumatoid Arthritis. * **Option D:** **Subcutaneous nodules** are firm, painless, and typically located over **bony prominences or extensor surfaces** (e.g., olecranon, patella), not flexor aspects. They are strongly associated with severe carditis. **Clinical Pearls for NEET-PG:** * **JONES Criteria Mnemonic:** **J**oints (Polyarthritis), **O** (Carditis - shaped like a heart), **N**odules, **E**rythema marginatum, **S**ydenham chorea. * **Echo-Carditis:** Subclinical carditis (detected only by Echo) is now considered a **Major Criterion** in all populations. * **Arthralgia vs. Arthritis:** In high-risk populations, monoarthritis or polyarthralgia can be considered major criteria. * **Chorea Exception:** If chorea is present, you do not need evidence of a preceding Strep infection to diagnose ARF.

Q: A newborn was diagnosed with a congenital abnormality resulting in transposition of great vessels. While preparing the infant for surgery, the medical team needed to keep the ductus arteriosus open. They achieved this by infusing:

Alprostadil. **Explanation:** In **Transposition of the Great Arteries (TGA)**, the pulmonary and systemic circulations function in parallel rather than in series. This condition is incompatible with life unless there is a communication (shunting) between the two circuits to allow mixing of oxygenated and deoxygenated blood. The **Ductus Arteriosus** provides this vital shunt in the neonatal period. **Why Alprostadil is correct:** **Alprostadil (Prostaglandin E1/PGE1)** is a potent vasodilator. In utero, endogenous prostaglandins keep the ductus arteriosus patent. After birth, oxygen levels rise and prostaglandin levels fall, leading to ductal closure. Administering exogenous Alprostadil maintains the patency of the ductus (**"PDA maintenance"**), ensuring adequate systemic oxygenation until definitive surgical correction (e.g., Arterial Switch Operation) can be performed. **Why the other options are incorrect:** * **Indomethacin:** This is a NSAID that inhibits prostaglandin synthesis. It is used to **close** a patent ductus arteriosus (PDA) in premature infants, which would be fatal in this clinical scenario. * **Cortisol:** While glucocorticoids are used in neonatology for lung maturity (antenatal) or refractory hypotension, they have no role in maintaining ductal patency. * **Tacrolimus:** An immunosuppressant (calcineurin inhibitor) used to prevent organ transplant rejection; it has no effect on the ductus arteriosus. **NEET-PG High-Yield Pearls:** * **Ductus-dependent lesions:** Include TGA, Tricuspid Atresia, Coarctation of the Aorta, and Hypoplastic Left Heart Syndrome. All require PGE1. * **Side effect of Alprostadil:** **Apnea** is a common side effect; clinicians must be prepared for intubation. * **Closure of PDA:** Pharmacological closure is achieved via **Indomethacin or Ibuprofen** (IV). * **Anatomical Remnant:** The closed ductus arteriosus becomes the **Ligamentum Arteriosum**.

Q: Congenital long QT syndrome is associated with neonatal:

Sinus bradycardia. **Explanation:** **1. Why Sinus Bradycardia is Correct:** Congenital Long QT Syndrome (LQTS) is a channelopathy characterized by delayed repolarization of the myocardium. In neonates, this delay in the electrical cycle often manifests as **fetal or neonatal sinus bradycardia**. The underlying mechanism involves a prolonged refractory period of the ventricular myocardium, which can exert an inhibitory effect on the sinoatrial (SA) node or result in a functional 2:1 atrioventricular (AV) block. Bradycardia is often the earliest clinical sign of LQTS and can be detected in utero during routine fetal monitoring. **2. Why Other Options are Incorrect:** * **Sinus Tachycardia:** This is physiologically opposite to the presentation of LQTS. LQTS patients typically have a lower-than-normal heart rate for their age. * **Supraventricular Tachycardia (SVT):** While SVT is a common neonatal arrhythmia, it is not specifically associated with the pathophysiology of LQTS. * **Ventricular Tachycardia (VT):** While LQTS can lead to a specific type of polymorphic VT known as *Torsades de Pointes*, the question asks for the most characteristic neonatal association. Sinus bradycardia is a more consistent finding in the neonatal period and often precedes the development of life-threatening ventricular arrhythmias. **3. High-Yield Clinical Pearls for NEET-PG:** * **Jervell and Lange-Nielsen Syndrome:** Autosomal recessive LQTS associated with **sensorineural deafness**. * **Romano-Ward Syndrome:** Autosomal dominant LQTS (more common, no deafness). * **Torsades de Pointes:** The classic "twisting of points" polymorphic VT seen in LQTS; treated with **Magnesium Sulfate**. * **Neonatal Screening:** Any neonate with persistent unexplained bradycardia should receive an ECG to measure the QTc interval (Normal 470ms is suspicious).

Q: Which of the following statements is false about erythema marginatum?

Clears from the center and leaves a rash behind. **Explanation:** **Erythema Marginatum** is a hallmark cutaneous manifestation of **Acute Rheumatic Fever (ARF)** and serves as one of the Major Criteria in the **Jones Criteria** [1]. 1. **Why Option B is the correct (False) statement:** Erythema marginatum is characterized by its **evanescent (fleeting)** nature. It begins as pinkish-red macules or papules that spread peripherally. As the lesion expands, it **clears centrally**, leaving a sharp, wavy, or "serpiginous" erythematous border. Crucially, it **does not leave a permanent rash or scar behind**; the skin returns to its normal appearance once the lesion fades. 2. **Analysis of Incorrect Options:** * **Option A:** True. The rash typically starts as small, non-pruritic pink papules that extend outward. * **Option C:** True. It is the pathognomonic skin manifestation of ARF, though it occurs in less than 5% of patients. * **Option D:** True. In the context of ARF, erythema marginatum is almost exclusively seen in patients who also have **carditis** [1]. It is rarely, if ever, seen as an isolated finding. **Clinical Pearls for NEET-PG:** * **Morphology:** Non-pruritic, non-tender, blanching, and serpiginous (snake-like) borders. * **Location:** Primarily affects the **trunk and proximal extremities**; it characteristically **spares the face**. * **Triggers:** The rash is transient and can be accentuated by the application of heat (e.g., a hot shower). * **Association:** Highly specific for ARF and strongly associated with a higher risk of underlying rheumatic heart disease [1].

Question 1

In Tetralogy of Fallot, when does the foramen ovale close?

Accepted Answer

Never

Answer

6 months

Answer

2 years

Answer

1 year

Question 2

In a patient of rheumatic carditis, for how long is the full dose of steroid typically given?

Accepted Answer

12 weeks

Answer

3 weeks

Answer

6 weeks

Answer

9 weeks

Question 3

Which of the following is considered one of Nada's major criteria for the clinical diagnosis of congenital heart disease?

Accepted Answer

Diastolic murmur

Answer

Systolic murmur grade I or II

Answer

Abnormal blood pressure

Answer

Abnormal electrocardiogram

Question 4

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?

Accepted Answer

Endocardial cushion defect

Answer

Atrial septal defect

Answer

Berry aneurysm

Answer

Coarctation of the aorta

Question 5

Which one of the following is not included as a major criterion in the Jones criteria?

Accepted Answer

Elevated ESR

Answer

Pancarditis

Answer

Arthritis

Answer

Subcutaneous nodules

Question 6

A two-month-old infant presents with marked respiratory distress, cyanosis, and bilateral crepitations. The infant's heart rate is 180/min, respiratory rate is 56/min, and the liver span is 7.5 cm. The child has had repeated episodes of fever, cough, and respiratory distress since birth. Cardiovascular examination reveals a grade III ejection systolic murmur in the left parasternal area. Chest X-ray shows cardiomegaly with a narrow base and plethoric lung fields. What is the most likely diagnosis?

Accepted Answer

Transposition of great arteries

Answer

Congenital methemoglobinemia

Answer

Cystic fibrosis

Answer

Tetralogy of Fallot

Question 7

Which of the following statements is true regarding the major criteria for Jones in acute rheumatic fever?

Accepted Answer

Sydenham chorea is a late manifestation.

Answer

Carditis is the earliest clinical manifestation seen in acute rheumatic fever.

Answer

Involvement of small joints is a characteristic feature.

Answer

Subcutaneous nodules are seen on flexor aspects of the limbs.

Question 8

A newborn was diagnosed with a congenital abnormality resulting in transposition of great vessels. While preparing the infant for surgery, the medical team needed to keep the ductus arteriosus open. They achieved this by infusing:

Accepted Answer

Alprostadil

Answer

Cortisol

Answer

Indomethacin

Answer

Tacrolimus

Question 9

Congenital long QT syndrome is associated with neonatal:

Accepted Answer

Sinus bradycardia

Answer

Sinus tachycardia

Answer

Supraventricular tachycardia

Answer

Ventricular tachycardia

Question 10

Which of the following statements is false about erythema marginatum?

Accepted Answer

Clears from the center and leaves a rash behind

Answer

Begins as a pink papule

Answer

Is the classical rash of acute rheumatic fever

Answer

Occurs only in patients with carditis

Cardiology — MCQs

Cardiology — MCQs

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