Cardiology — MCQs
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Which one of the following is not included as a major criterion in the Jones criteria?
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?
Which of the following statements is true regarding the major criteria for Jones in acute rheumatic fever?
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:
What is the treatment of choice for Kawasaki disease?
What maternal condition should be evaluated in a fetus diagnosed with congenital heart block?
A 16-year-old boy is found to have hypertension on routine evaluation. He has no symptoms of shortness of breath or chest discomfort, but occasionally on exertion notes that his legs get tired easily. On physical examination, the blood pressure in his arms is 140/90 mm Hg bilaterally. Measurement of the blood pressure in his legs is 20 mm Hg lower than in the arms. Which of the following is the most likely diagnosis?
What is the most common presentation of a double aortic arch in infants?
Which of the following statements is NOT true about Tetralogy of Fallot (TOF)?
Which of the following can cause recurrent pulmonary infections, except?
Cardiology Indian Medical PG Practice Questions and MCQs
Question 11: Which one of the following is not included as a major criterion in the Jones criteria?
- A. Pancarditis
- B. Arthritis
- C. Subcutaneous nodules
- D. Elevated ESR (Correct Answer)
Explanation: 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**).
Question 12: 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?
- A. Congenital methemoglobinemia
- B. Transposition of great arteries (Correct Answer)
- C. Cystic fibrosis
- D. Tetralogy of Fallot
Explanation: **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.
Question 13: Which of the following statements is true regarding the major criteria for Jones in acute rheumatic fever?
- A. Carditis is the earliest clinical manifestation seen in acute rheumatic fever.
- B. Sydenham chorea is a late manifestation. (Correct Answer)
- C. Involvement of small joints is a characteristic feature.
- D. Subcutaneous nodules are seen on flexor aspects of the limbs.
Explanation: ### 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.
Question 14: 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:
- A. Cortisol
- B. Indomethacin
- C. Alprostadil (Correct Answer)
- D. Tacrolimus
Explanation: **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**.
Question 15: What is the treatment of choice for Kawasaki disease?
- A. Intravenous immunoglobulin (Correct Answer)
- B. Steroids
- C. Azathioprine
- D. Not recalled
Explanation: **Explanation:** Kawasaki Disease (KD) is an acute, self-limiting systemic medium-vessel vasculitis with a predilection for the coronary arteries. **1. Why Intravenous Immunoglobulin (IVIG) is the Correct Answer:** The primary goal of treating KD is to reduce systemic inflammation and prevent the development of **coronary artery aneurysms (CAAs)**. High-dose IVIG (2 g/kg as a single infusion) is the gold standard because it exerts a generalized anti-inflammatory effect and modulates the immune response. When administered within the first 10 days of illness, IVIG reduces the incidence of CAAs from 25% to less than 5%. It is typically given alongside high-dose Aspirin. **2. Why Other Options are Incorrect:** * **Steroids (B):** While used in "IVIG-resistant" cases or as primary therapy in high-risk patients (e.g., Kobayashi score), they are not the first-line treatment of choice for all patients. Historically, there was a concern that steroids alone might increase aneurysm risk, though modern data suggests they are useful as adjunctive therapy. * **Azathioprine (C):** This is an immunosuppressant used in chronic conditions like SLE or vasculitides like GPA. It has no role in the acute management of Kawasaki disease. **Clinical Pearls for NEET-PG:** * **Aspirin Paradox:** KD is one of the few pediatric conditions where Aspirin is indicated despite the risk of Reye’s syndrome (used in high doses for anti-inflammatory effects initially, then low doses for anti-platelet effects). * **Diagnosis:** It is a clinical diagnosis (Fever for ≥5 days + 4 out of 5 criteria: Conjunctivitis, Rash, Edema/Erythema of hands/feet, Adenopathy, Mucosal changes). * **Vaccination:** Live vaccines (MMR, Varicella) should be delayed for **11 months** after receiving IVIG. * **Most common cause** of acquired heart disease in children in developed nations.
Question 16: What maternal condition should be evaluated in a fetus diagnosed with congenital heart block?
- A. Antiphospholipid syndrome
- B. Congenital heart defects
- C. Systemic lupus erythematosus (Correct Answer)
- D. Hemolytic anemia
Explanation: **Explanation:** The diagnosis of **congenital heart block (CHB)** in a fetus or neonate is strongly associated with maternal autoimmune diseases, most notably **Systemic Lupus Erythematosus (SLE)** and Sjögren’s syndrome. The underlying mechanism involves the transplacental passage of maternal **anti-Ro (SS-A)** and **anti-La (SS-B)** antibodies. These IgG antibodies cross the placenta (typically between 18–24 weeks of gestation) and cause an inflammatory reaction (myocarditis) followed by progressive fibrosis and calcification of the fetal AV node. This damage is permanent and results in a complete (third-degree) heart block. Notably, many mothers are asymptomatic at the time of fetal diagnosis and are only diagnosed with SLE or Sjögren’s after the heart block is detected. **Analysis of Incorrect Options:** * **A. Antiphospholipid syndrome:** While often co-existing with SLE, it is primarily associated with recurrent miscarriages and thrombotic events rather than fetal conduction defects. * **B. Congenital heart defects:** While structural defects (like Left Atrial Isomerism) can cause heart block, the question asks for a *maternal condition* to be evaluated. * **D. Hemolytic anemia:** This is not a known cause of fetal conduction system destruction. **High-Yield Pearls for NEET-PG:** * **Antibodies:** Anti-Ro (SS-A) is the most specific marker for Neonatal Lupus/CHB. * **Neonatal Lupus:** Besides CHB, it presents with a characteristic "raccoon-eye" or periorbital rash and cytopenias. * **Reversibility:** The skin and hematological manifestations are transient (disappear as maternal antibodies wane), but the **heart block is permanent** and often requires a pacemaker. * **Treatment:** Maternal fluorinated corticosteroids (e.g., Dexamethasone) may be used to reduce fetal inflammation, but they cannot reverse a complete block.
Question 17: A 16-year-old boy is found to have hypertension on routine evaluation. He has no symptoms of shortness of breath or chest discomfort, but occasionally on exertion notes that his legs get tired easily. On physical examination, the blood pressure in his arms is 140/90 mm Hg bilaterally. Measurement of the blood pressure in his legs is 20 mm Hg lower than in the arms. Which of the following is the most likely diagnosis?
- A. Aortic insufficiency
- B. Coarctation of the aorta (Correct Answer)
- C. Normal variant
- D. Ventricular aneurysm
Explanation: ### Explanation **Correct Answer: B. Coarctation of the aorta** The clinical presentation of hypertension in the upper extremities combined with lower blood pressure in the lower extremities is a classic hallmark of **Coarctation of the Aorta (CoA)**. **Underlying Concept:** CoA is a congenital narrowing of the aorta, typically occurring near the insertion of the ductus arteriosus (juxtaductal). This narrowing creates a pressure gradient: high pressure proximal to the obstruction (arms/head) and low pressure distal to it (legs). The "tired legs" on exertion described by the patient is **claudication**, caused by inadequate blood flow to the lower limbs. **Analysis of Incorrect Options:** * **A. Aortic Insufficiency:** Characterized by a wide pulse pressure and "Hill’s sign" (where popliteal systolic pressure is significantly *higher* than brachial pressure), which is the opposite of this case. * **C. Normal Variant:** In a healthy individual, the blood pressure in the legs is typically 10–20 mmHg *higher* than in the arms due to the summation of reflected pressure waves. A lower pressure in the legs is always pathological. * **D. Ventricular Aneurysm:** Usually a complication of myocardial infarction; it presents with heart failure or arrhythmias, not a differential limb blood pressure gradient. **NEET-PG High-Yield Pearls:** * **Physical Exam:** Look for "radio-femoral delay" and a systolic murmur heard best over the left infrascapular area. * **X-ray Findings:** "Rib notching" (due to collateral flow through intercostal arteries) and the "3 sign" on the aortic contour. * **Associations:** Strongly associated with **Turner Syndrome** (30% 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 18: What is the most common presentation of a double aortic arch in infants?
- A. Dysphagia
- B. Tracheal compression symptoms (Correct Answer)
- C. Positional hyperemia with right upper arm edema
- D. Bleeding
Explanation: **Explanation:** **Double Aortic Arch (DAA)** is the most common type of symptomatic vascular ring. It occurs when both the right and left embryonic fourth aortic arches persist, forming a complete ring around the trachea and esophagus. **1. Why Tracheal Compression is Correct:** In infants, the trachea is highly compliant and easily compressible. Because the ring tightly encircles the airway, the most frequent and earliest clinical manifestations are respiratory. These include **expiratory stridor** (often called "noisy breathing"), barking cough, and respiratory distress. While the esophagus is also compressed, respiratory symptoms typically predominate and present earlier than feeding difficulties. **2. Analysis of Incorrect Options:** * **A. Dysphagia:** While esophageal compression occurs (dysphagia lusoria), it is usually less prominent than respiratory distress in infancy. It may become more apparent when the child starts solid foods. * **C. Positional hyperemia/Edema:** These are features of venous obstruction (like Superior Vena Cava Syndrome) or thoracic outlet syndrome, not a vascular ring. * **D. Bleeding:** This is not a feature of DAA. Hemoptysis or hematemesis would only occur in rare, late-stage complications like an aorto-esophageal fistula. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** CT or MRI angiography (to visualize the vascular anatomy). * **Initial Screening:** Barium swallow (shows bilateral/posterior indentation of the esophagus). * **Physical Exam:** Stridor often improves with **neck hyperextension** (which pulls the ring away from the trachea). * **Anatomy:** The **right arch** is usually larger and higher than the left arch in a DAA.
Question 19: Which of the following statements is NOT true about Tetralogy of Fallot (TOF)?
- A. It is the most common congenital cyanotic heart disease in children.
- B. The severity of the disease depends on the severity of pulmonary stenosis.
- C. Atrial septal defect is one of the components of TOF. (Correct Answer)
- D. A boot-shaped heart is seen on chest X-ray.
Explanation: **Explanation:** Tetralogy of Fallot (TOF) is defined by a specific constellation of four anatomical defects. Understanding these components is crucial for identifying the incorrect statement. **1. Why Option C is the correct answer (The "NOT true" statement):** The four classic components of TOF are: 1. **Ventricular Septal Defect (VSD):** Large and malaligned. 2. **Overriding of the Aorta:** The aorta sits over the VSD. 3. **Right Ventricular Outflow Tract Obstruction (RVOTO):** Most commonly infundibular pulmonary stenosis. 4. **Right Ventricular Hypertrophy (RVH):** Occurs secondary to the high pressure required to pump against the obstruction. An **Atrial Septal Defect (ASD)** is not a component of the "Tetralogy." When an ASD is present along with TOF, the condition is known as **Pentalogy of Fallot.** **2. Analysis of incorrect options:** * **Option A:** TOF is indeed the most common cyanotic heart disease (CHD) beyond infancy. (Note: Transposition of the Great Arteries is the most common cyanotic CHD at birth). * **Option B:** The degree of cyanosis and clinical severity are directly proportional to the severity of pulmonary stenosis. More obstruction leads to more right-to-left shunting across the VSD. * **Option D:** The "boot-shaped heart" (**Coeur en sabot**) is a classic radiological finding caused by an upturned apex (due to RVH) and a concave pulmonary segment. **Clinical Pearls for NEET-PG:** * **Murmur:** The murmur in TOF is due to **pulmonary stenosis** (ejection systolic), NOT the VSD (which is usually large and non-restrictive). * **X-ray:** Characterized by "Oligaemic lung fields" due to reduced pulmonary blood flow. * **Management:** Squatting helps during a "Tet spell" by increasing systemic vascular resistance, which reduces the right-to-left shunt. * **Drug of Choice for Tet Spell:** Morphine or Beta-blockers (Propranolol).
Question 20: Which of the following can cause recurrent pulmonary infections, except?
- A. Ventricular Septal Defect (VSD)
- B. Recurrent lower respiratory tract infections
- C. Tetralogy of Fallot (TOF) (Correct Answer)
- D. Atrial Septal Defect (ASD)
Explanation: **Explanation:** The core concept behind recurrent pulmonary infections in congenital heart disease (CHD) is **increased pulmonary blood flow (Left-to-Right Shunt)**. When excess blood reaches the lungs, it leads to pulmonary congestion, interstitial edema, and decreased lung compliance. This fluid-rich environment impairs local immune mechanisms and provides a nidus for bacterial growth, leading to frequent pneumonia. * **Why Tetralogy of Fallot (TOF) is the correct answer:** TOF is a **cyanotic** heart disease characterized by **decreased pulmonary blood flow** due to right ventricular outflow tract obstruction (pulmonary stenosis). Because the lungs are "protected" from high pressure and volume, these patients do not typically suffer from recurrent pulmonary infections. Instead, they present with cyanosis and "Tet spells." * **Why the other options are incorrect:** * **VSD & ASD:** These are **Acyanotic** CHDs with **Left-to-Right shunts**. They cause pulmonary plethora (increased blood flow), making the patient highly susceptible to recurrent lower respiratory tract infections (LRTIs). VSD usually presents earlier and more severely than ASD. * **Recurrent LRTIs:** This option is a clinical manifestation of the underlying shunt physiology mentioned above. **Clinical Pearls for NEET-PG:** 1. **Acyanotic CHD (VSD, ASD, PDA):** Increased pulmonary blood flow → Recurrent LRTIs + Congestive Heart Failure. 2. **Cyanotic CHD (TOF, Tricuspid Atresia):** Decreased pulmonary blood flow → Cyanosis + Hypoxic spells (No recurrent LRTIs). 3. **Exception:** Transposition of the Great Arteries (TGA) is a cyanotic CHD that *can* have increased pulmonary flow and thus may present with infections. 4. **VSD** is the most common congenital heart disease overall.
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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