Cardiology Practice Questions

Q: Which one of the following congenital heart diseases presents with cyanosis without cardiomegaly and/or congestive heart failure?

Fallot's tetralogy. **Explanation:** The hallmark of **Tetralogy of Fallot (TOF)** is cyanosis with **decreased pulmonary blood flow**. In TOF, the right ventricular outflow tract (RVOT) obstruction limits blood flow to the lungs. Because the right ventricle (RV) can decompress into the left ventricle via the large VSD, there is no volume overload. Consequently, the heart size remains normal (though the apex may be upturned, forming the classic "boot-shaped" heart or *coeur en sabot*), and **congestive heart failure (CHF) is characteristically absent** in an uncomplicated TOF. **Analysis of Incorrect Options:** * **Transposition of Great Arteries (TGA):** This is a cyanotic heart disease with *increased* pulmonary blood flow. It typically presents with early-onset CHF and cardiomegaly (the "egg-on-a-string" appearance). * **Congenital Mitral Regurgitation:** This causes volume overload of the left atrium and left ventricle, leading to significant cardiomegaly and symptoms of left-sided heart failure. It is generally acyanotic. * **Congenital Pulmonary Stenosis:** While it may cause cyanosis if there is an associated right-to-left shunt (e.g., via a patent foramen ovale), severe stenosis leads to pressure overload and right-sided heart failure (manifesting as hepatomegaly and edema). **High-Yield Clinical Pearls for NEET-PG:** * **The "Rule of TOF":** If a cyanotic infant has a **small heart** and **clear lung fields** (oligemic lung fields) on X-ray, think TOF. * **CHF in TOF:** If a patient with TOF develops heart failure, suspect an associated complication like severe anemia or an infective endocarditis. * **Squatting episodes:** These increase systemic vascular resistance, forcing more blood through the RVOT into the lungs, thereby relieving cyanotic spells.

Q: In a 5-year-old child, instead of the physiological splitting of the second heart sound (S2), which is expected only during inspiration, a wide and fixed split of S2 is heard during both inspiration and expiration. What condition is associated with this finding?

Atrial septal defect. ### Explanation **1. Why Atrial Septal Defect (ASD) is the Correct Answer:** The hallmark of an ASD is a **wide and fixed split S2**. * **Wide Split:** In ASD, the left-to-right shunt increases the blood volume in the right ventricle (RV), prolonging RV ejection time and delaying the closure of the pulmonary valve (P2). * **Fixed Split:** Normally, inspiration increases venous return to the right heart, delaying P2. In ASD, during expiration, the drop in systemic venous return is compensated by an *increase* in the left-to-right shunt across the defect. This keeps the RV stroke volume constant throughout the respiratory cycle, ensuring the interval between A2 and P2 remains unchanged (fixed). **2. Why Other Options are Incorrect:** * **Ventricular Septal Defect (VSD):** Typically presents with a **pansystolic murmur**. While S2 may be wide (due to early A2 closure or delayed P2), it is **not fixed**; it still varies with respiration. * **Mitral Regurgitation (MR):** Causes a wide split S2 because the left ventricle empties faster (into both the aorta and left atrium), leading to early closure of the aortic valve (A2). However, the split remains **variable** with respiration. * **Pulmonary Stenosis (PS):** Causes a **wide and variable** split S2. P2 is delayed due to prolonged RV ejection against resistance, but the split widens further during inspiration. **3. Clinical Pearls for NEET-PG:** * **ASD Murmur:** The murmur in ASD is a **midsystolic flow murmur** at the pulmonary area (due to increased flow across the pulmonary valve), NOT due to flow across the defect itself. * **Ostium Secundum:** The most common type of ASD (75%). * **ECG Finding:** Look for **RSR' pattern** in V1 (incomplete RBBB) and right axis deviation. * **Key Distinction:** If a split S2 is wide but *moves* with respiration, think PS or RBBB. If it is wide and *fixed*, it is almost always ASD.

Q: Which cardiac anomaly is associated with Tetralogy of Fallot?

Atrial septal defect. **Explanation:** The question asks for an *associated* cardiac anomaly rather than one of the four primary components of Tetralogy of Fallot (TOF). **1. Why Atrial Septal Defect (ASD) is the correct answer:** While TOF is classically defined by four features, a significant number of patients (approx. 10-15%) also present with an associated **Atrial Septal Defect**. When an ASD is present alongside the classic four features of TOF, the condition is clinically referred to as **"Pentalogy of Fallot."** In the context of NEET-PG, "associated" usually refers to an additional finding beyond the diagnostic criteria. **2. Why the other options are incorrect:** * **Cyanotic heart disease (A):** This is a *classification* of the disease, not a specific anatomical anomaly. TOF is the most common cyanotic congenital heart disease (CCHD) after the first year of life. * **Right ventricular hypertrophy (B) and Ventricular septal defect (D):** These are **primary components** of TOF, not "associated" anomalies. The four classic components are: 1. Subpulmonic stenosis (Infundibular stenosis) 2. Overriding of aorta 3. Large malaligned VSD 4. Right Ventricular Hypertrophy (RVH) **3. NEET-PG High-Yield Pearls:** * **Most common associated anomaly:** Right-sided aortic arch (seen in 25% of cases). * **X-ray finding:** "Boot-shaped heart" (Coeur en sabot) due to an upturned apex (RVH) and small pulmonary artery segment. * **ECG finding:** Right axis deviation and RVH. * **Management:** Squatting position during a "Tet spell" increases systemic vascular resistance (SVR), decreasing the right-to-left shunt. * **Drug of choice for Tet spell:** Morphine (to calm the child and reduce infundibular spasm) and Beta-blockers (Propranolol).

Q: A 5-year-old child presents with exertional dyspnea and a history of cyanotic spells. On examination, there is clubbing and a harsh systolic murmur heard at the left upper sternal border. Chest X-ray is shown below. What is the most likely diagnosis?

Tetralogy of Fallot. ***Tetralogy of Fallot*** - The clinical triad of **exertional dyspnea**, **cyanotic spells** (tet spells), and a **harsh systolic murmur** at the left upper sternal border (due to pulmonary stenosis) is classic for this condition. - The chest X-ray shows a characteristic **"boot-shaped heart"** (coeur en sabot), which results from **right ventricular hypertrophy** (forming the toe) and a concave main pulmonary artery segment. *Total Anomalous Pulmonary Venous Connection* - The classic chest X-ray finding for TAPVC is a **"snowman sign"** or **"figure-of-eight"** appearance, which is not seen in the provided image. - While it is a cyanotic condition, it results from the mixing of oxygenated and deoxygenated blood and is associated with signs of right heart failure and pulmonary edema. *Transposition of the Great Arteries* - This condition typically presents with severe **cyanosis at birth** and requires immediate intervention for survival; presentation at age 5 is highly unlikely without prior surgery. - The characteristic radiographic sign is an **"egg-on-a-string"** appearance with a narrow superior mediastinum, differing from the boot shape seen here. *Atrial Septal Defect* - An ASD is an **acyanotic** heart defect (left-to-right shunt), so it does not cause cyanotic spells or clubbing in a 5-year-old. - The hallmark physical finding is a **wide, fixed splitting of S2**, not a harsh systolic murmur.

Q: A child presents with kawasaki disease with multiple small coronary artery aneurysms. Treatment is?

Aspirin for 6 weeks. ***Aspirin for 6 weeks*** - After the acute phase is treated with **IVIG** and high-dose aspirin, the regimen is switched to low-dose aspirin for its **antiplatelet** effects to prevent thrombosis in the affected coronary arteries. - This low-dose therapy is typically continued for 6-8 weeks, at which point a follow-up **echocardiogram** is performed and inflammatory markers (like **ESR** and **CRP**) should have normalized. *Aspirin lifelong* - Lifelong antiplatelet therapy is generally reserved for patients with **large** or **giant** coronary artery aneurysms due to a high risk of **thrombosis** and stenosis. - For small aneurysms, which often resolve, therapy is guided by serial echocardiograms and is not typically lifelong from the outset. *Aspirin for 4 weeks* - A 4-week duration is insufficient, as it may not cover the entire period of coronary wall inflammation and thrombocytosis, which usually peaks in the subacute phase. - The standard follow-up interval for re-evaluation with an **echocardiogram** is at 6-8 weeks, making it logical to continue therapy at least until that point. *Aspirin and clopidogrel for 6 weeks* - **Dual antiplatelet therapy** with aspirin and clopidogrel is recommended for patients with **medium-sized** or **giant** coronary artery aneurysms, not for small aneurysms. - The flowchart provided indicates that for small aneurysms (Z score ≥2.5 to <5), **single antiplatelet therapy** with low-dose aspirin is the appropriate treatment.

Q: What could be the possible diagnosis for a newborn exhibiting weak lower limb pulses and strong upper limb pulses?

COA. ***COA*** (Coarctation of the Aorta) - The classic presentation of **Coarctation of the Aorta** involves a narrowing of the aorta, usually distal to the left subclavian artery, leading to increased pressure proximal to the coarctation (strong upper limb pulses) and decreased pressure distal to it (weak lower limb pulses). - This severe pressure gradient is manifested as **differential pulses** and potential **blood pressure discrepancy** between the arms and legs, making this the most likely diagnosis. *TGA* - **Transposition of the Great Arteries** is characterized by severe **cyanosis** presenting shortly after birth due to two parallel circulations (aorta from RV, pulmonary artery from LV). - It does not typically cause a significant differential in pulse strength between the upper and lower limbs unless complicated by underlying aortic arch anomalies. *TOF* - **Tetralogy of Fallot** typically presents with cyanosis and **hypercyanotic spells** (**tet spells**) due to severe right ventricular outflow tract obstruction and a large VSD. - While it is a common cyanotic heart disease, it primarily affects flow to the pulmonary circulation and does not cause obstruction in the systemic aorta leading to differential pulses. *Ebstein anomaly* - This condition involves the apical displacement of the **tricuspid valve** leaflets into the **right ventricle**, leading to tricuspid regurgitation and large right atrium. - Clinical features usually include varying degrees of cyanosis and signs of right heart failure but do not typically involve a differential in systemic arterial pulses.

Q: A 9-month-old infant presents with severe respiratory distress, central cyanosis not improving with oxygen, and a harsh systolic murmur. Chest X-ray shows boot-shaped heart with decreased pulmonary vascular markings. Echocardiography confirms the diagnosis. What is the most likely underlying cardiac defect?

Tetralogy of Fallot. ***Tetralogy of Fallot*** - The combination of **severe respiratory distress**, **central cyanosis** unresponsive to oxygen (a **cyanotic spell**), **harsh systolic murmur** (due to **pulmonary stenosis**), and a **boot-shaped heart** (coeur en sabot) on chest X-ray with **decreased pulmonary vascular markings** (due to reduced blood flow) is the classic presentation of **Tetralogy of Fallot** (TOF). - TOF is the most common cyanotic congenital heart disease and consists of four defects: large **VSD**, **pulmonary stenosis**, **overriding aorta**, and **right ventricular hypertrophy**. *Transposition of Great Arteries (TGA)* - TGA presents with severe cyanosis, but the chest X-ray typically shows a **'egg-on-a-string'** appearance due to a narrow mediastinum and cardiomegaly, not a boot shape. - Pulmonary vascular markings are often **increased** or normal, depending on whether there is associated pulmonary stenosis, and the murmur is typically non-specific or absent. *Total Anomalous Pulmonary Venous Return (TAPVR)* - This condition presents with cyanosis and can show a **'snowman'** or **'figure-of-eight'** sign on the chest X-ray if the supra-cardiac type is present, due to enlarged vertical vein and SVC. - Pulmonary vascular markings are usually **increased** due to pulmonary venous obstruction. *Truncus Arteriosus* - Although cyanotic, truncus arteriosus is characterized by a single great artery overriding the ventricular septum, leading to **increased pulmonary blood flow** and consequently **increased pulmonary vascular markings** on the chest X-ray. - The heart shape is typically **cardiomegaly** with a common trunk arising from the heart, often resulting in a late-onset or subtle cyanosis compared to TOF or TGA.

Q: A 4-year-old child presents with high-grade fever for 5 days, bilateral non-purulent conjunctival injection, strawberry tongue, cervical lymphadenopathy (>1.5 cm), and polymorphous rash. On day 6, desquamation of fingertips begins. Echocardiography shows coronary artery dilation. What is the most appropriate immediate treatment?

Intravenous immunoglobulin (IVIG) with aspirin. ***Intravenous immunoglobulin (IVIG) with aspirin*** - This is the **gold standard, immediate treatment** for acute Kawasaki disease to reduce systemic inflammation and prevent coronary artery complications - **IVIG** (2 g/kg as a single infusion over 10-12 hours) works by modulating the immune response and reducing inflammation - **High-dose aspirin** (80-100 mg/kg/day divided into 4 doses) provides anti-inflammatory effects during the acute febrile phase - This combination must be started **within 10 days of fever onset** (ideally within 7 days) to significantly reduce the risk of **coronary artery aneurysms** - Given that this child already has coronary artery dilation on echo, urgent IVIG + aspirin therapy is critical to prevent progression *High-dose aspirin alone* - Aspirin alone is **insufficient** to address the underlying immune-mediated vasculitis in Kawasaki disease - While aspirin has anti-inflammatory and antiplatelet effects, it does **not provide the immunomodulatory benefits** of IVIG - Monotherapy with aspirin has been shown to be **significantly less effective** at preventing coronary complications compared to combination therapy *Supportive care only* - Supportive care (hydration, antipyretics) addresses symptoms but **does not treat the underlying vasculitis** - Without specific immunomodulatory therapy, up to **25% of untreated KD patients** develop coronary artery aneurysms - This child already has coronary involvement, making specific therapy even more urgent *Oral corticosteroids* - Corticosteroids are generally reserved for **IVIG-refractory cases** (patients who remain febrile 36-48 hours after initial IVIG) or high-risk patients - They are **not recommended as first-line therapy** according to current AHA guidelines - IVIG remains superior for initial treatment in preventing coronary complications

Q: A 3-year-old child is brought to the clinic with a history of cyanosis since infancy. Which of the following is a component of Tetralogy of Fallot (TOF)?

Infundibular pulmonary stenosis. ***Infundibular pulmonary stenosis*** - This is the most common anatomic type of **pulmonary stenosis** seen in TOF, caused by hypertrophy of the muscle below the pulmonary valve (infundibulum). - The degree of this stenosis dictates the direction of flow across the VSD and, consequently, the severity of **cyanosis**. *Inter atrial septal defect* - An ASD is not a primary component of TOF. When TOF is associated with an ASD, the condition is termed **Pentalogy of Fallot**. - ASD typically causes a **left-to-right shunt** and is usually an acyanotic or late-onset cyanotic condition, unlike classic TOF. *Left ventricular hypertrophy (LVH)* - The pressure overload due to **pulmonary stenosis** and the large **VSD** leads to **Right Ventricular Hypertrophy (RVH)**. - LVH suggests conditions like severe **aortic stenosis** or systemic overloading, not the typical hemodynamics of TOF. *Transposition of the great arteries (TGA)* - **TGA** is a separate, distinct cyanotic congenital heart disease where the great arteries are transposed (aorta from RV, pulmonary artery from LV). - The components of TOF involve a single great artery relationship but with a large **Ventricular Septal Defect (VSD)** and overriding aorta.

Question 1

Which of the following conditions causes congestive heart failure in neonates?

Accepted Answer

Total anomalous pulmonary venous return (TAPVR)

Answer

Bicuspid aortic valve

Answer

Tetralogy of Fallot

Answer

Atrial septal defect (ASD)

Question 2

Which one of the following congenital heart diseases presents with cyanosis without cardiomegaly and/or congestive heart failure?

Accepted Answer

Fallot's tetralogy

Answer

Transposition of great arteries

Answer

Congenital mitral regurgitation

Answer

Congenital pulmonary stenosis

Question 3

In a 5-year-old child, instead of the physiological splitting of the second heart sound (S2), which is expected only during inspiration, a wide and fixed split of S2 is heard during both inspiration and expiration. What condition is associated with this finding?

Accepted Answer

Atrial septal defect

Answer

Ventricular septal defect

Answer

Mitral regurgitation

Answer

Pulmonary stenosis

Question 4

Which cardiac anomaly is associated with Tetralogy of Fallot?

Accepted Answer

Atrial septal defect

Answer

Cyanotic heart disease

Answer

Right ventricular hypertrophy

Answer

Ventricular septal defect

Question 5

A 5-year-old child presents with exertional dyspnea and a history of cyanotic spells. On examination, there is clubbing and a harsh systolic murmur heard at the left upper sternal border. Chest X-ray is shown below. What is the most likely diagnosis?

Accepted Answer

Tetralogy of Fallot

Answer

Total Anomalous Pulmonary Venous Connection

Answer

Atrial Septal Defect

Answer

Transposition of the Great Arteries

Question 6

A child presents with kawasaki disease with multiple small coronary artery aneurysms. Treatment is?

Accepted Answer

Aspirin for 6 weeks

Answer

Aspirin for 4 weeks

Answer

Aspirin lifelong

Answer

Aspirin and clopidogrel for 6 weeks

Question 7

What could be the possible diagnosis for a newborn exhibiting weak lower limb pulses and strong upper limb pulses?

Accepted Answer

COA

Answer

TOF

Answer

Ebstein anomaly

Answer

TGA

Question 8

A 9-month-old infant presents with severe respiratory distress, central cyanosis not improving with oxygen, and a harsh systolic murmur. Chest X-ray shows boot-shaped heart with decreased pulmonary vascular markings. Echocardiography confirms the diagnosis. What is the most likely underlying cardiac defect?

Accepted Answer

Tetralogy of Fallot

Answer

Total anomalous pulmonary venous return

Answer

Transposition of great arteries

Answer

Truncus arteriosus

Question 9

A 4-year-old child presents with high-grade fever for 5 days, bilateral non-purulent conjunctival injection, strawberry tongue, cervical lymphadenopathy (>1.5 cm), and polymorphous rash. On day 6, desquamation of fingertips begins. Echocardiography shows coronary artery dilation. What is the most appropriate immediate treatment?

Accepted Answer

Intravenous immunoglobulin (IVIG) with aspirin

Answer

High-dose aspirin alone

Answer

Supportive care only

Answer

Oral corticosteroids

Question 10

A 3-year-old child is brought to the clinic with a history of cyanosis since infancy. Which of the following is a component of Tetralogy of Fallot (TOF)?

Accepted Answer

Infundibular pulmonary stenosis

Answer

Inter atrial septal defect

Answer

Left ventricular hypertrophy (LVH)

Answer

Transposition of the great arteries (TGA)

Cardiology — MCQs

Cardiology — MCQs

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