Cardiology — MCQs

Cardiology Indian Medical PG Practice Questions and MCQs

Question 191: RBBB with left axis deviation is characteristic of which condition?

A. Ostium Primum ASD (Correct Answer)
B. Mitral valve prolapse
C. Patent Ductus Arteriosus
D. Ventricular Septal Defect

Explanation: **Explanation** The characteristic ECG finding of **Right Bundle Branch Block (RBBB) with Left Axis Deviation (LAD)** is a classic hallmark of **Ostium Primum Atrial Septal Defect (ASD)**. **Why Ostium Primum ASD is correct:** In Ostium Primum ASD (part of the endocardial cushion defect spectrum), the conduction system is anatomically displaced. The AV node and the Bundle of His are displaced posteriorly and inferiorly. This leads to early activation of the anterior left ventricle and delayed activation of the posterior-superior regions, resulting in **Left Axis Deviation** (usually -30° to -90°). The **RBBB** pattern (rsR' in V1) is caused by right ventricular volume overload due to the left-to-right shunt, leading to delayed depolarization of the right ventricle. **Why other options are incorrect:** * **Mitral Valve Prolapse (MVP):** Usually presents with a normal axis or non-specific ST-T wave changes. It is not associated with RBBB or LAD. * **Patent Ductus Arteriosus (PDA):** Typically shows **Left Ventricular Hypertrophy (LVH)** and a normal or leftward axis, but not RBBB. * **Ventricular Septal Defect (VSD):** Small VSDs have normal ECGs; large VSDs typically show **Biventricular Hypertrophy (Katz-Wachtel phenomenon)**. **High-Yield Clinical Pearls for NEET-PG:** * **Ostium Secundum ASD (Most common):** Shows RBBB with **Right Axis Deviation (RAD)**. * **Ostium Primum ASD:** Shows RBBB with **Left Axis Deviation (LAD)**. * **Tricuspid Atresia:** Also presents with LAD, but with **Left Ventricular Hypertrophy** and decreased pulmonary vascular markings (cyanotic heart disease). * **Katz-Wachtel Phenomenon:** Large mid-precordial biphasic QRS complexes seen in VSD.

Question 192: A 3-month-old infant is diagnosed with a deletion at the 22q11 chromosome. A routine cardiovascular examination reveals severe congenital cardiac malformation. Which of the following malformations will most likely be associated with 22q11 syndrome?

A. Tetralogy of Fallot and truncus arteriosus (Correct Answer)
B. Transposition of the great arteries
C. Atrial septal and ventricular septal defects
D. Coarctation of the aorta

Explanation: **Explanation:** The patient presents with **DiGeorge Syndrome (22q11.2 deletion syndrome)**, characterized by the mnemonic **CATCH-22**: **C**ardiac defects, **A**bnormal facies, **T**hymic hypoplasia (T-cell deficiency), **C**left palate, and **H**ypocalcemia (due to parathyroid hypoplasia). **Why Option A is Correct:** The 22q11 deletion results in the maldevelopment of the **3rd and 4th pharyngeal pouches**. This leads to defects in the **neural crest cells**, which are essential for the septation of the **outflow tract (conotruncus)** of the heart. Consequently, "conotruncal" or "cyanotic" heart defects are most common. **Tetralogy of Fallot (TOF)** is the most frequent, followed by **Truncus Arteriosus** and Interrupted Aortic Arch (Type B). **Why Other Options are Incorrect:** * **Option B (TGA):** While a cyanotic defect, TGA is not classically associated with 22q11 syndrome; it is more commonly associated with maternal diabetes. * **Option C (ASD/VSD):** These are common isolated defects or associated with Down Syndrome (Trisomy 21), particularly endocardial cushion defects (AVSD). * **Option D (Coarctation of the aorta):** This is the hallmark cardiac association for **Turner Syndrome (45, XO)**. **High-Yield Clinical Pearls for NEET-PG:** * **Most common defect in DiGeorge:** Tetralogy of Fallot. * **Most specific defect for DiGeorge:** Interrupted Aortic Arch (Type B) or Truncus Arteriosus. * **Immunology Link:** Patients have recurrent viral/fungal infections due to T-cell deficiency (absent thymic shadow on X-ray). * **Metabolic Link:** Seizures in the neonatal period may occur due to hypocalcemia (hypoparathyroidism).

Question 193: Which of the following is NOT a criterion for the diagnosis of Kawasaki disease?

A. Fever for at least 5 days
B. Bilateral non-exudative conjunctivitis (Correct Answer)
C. Coronary artery aneurysms
D. Cervical lymphadenopathy

Explanation: To diagnose **Kawasaki Disease (KD)**, clinicians use specific clinical criteria. The diagnosis is primarily clinical, based on the presence of high-grade fever and specific physical findings. ### **Why Option B is the "Correct" Answer (The Catch)** In the context of this specific question, there is a subtle but critical distinction. While bilateral non-exudative conjunctivitis **is** a classic feature of Kawasaki Disease, it is a **clinical sign**, whereas **Coronary Artery Aneurysms (Option C)** are a **complication**, not part of the diagnostic criteria used to define the disease. However, if the question implies which of these is *not* a diagnostic criterion according to the American Heart Association (AHA) guidelines, Option C is technically the correct answer because it is an outcome/sequela, not a criterion. *Note: If the question marks B as correct, it is likely a technical error in the source material, as non-exudative conjunctivitis is a core criterion. In standard NEET-PG patterns, **Option C** is the most common "distractor" because while it is the most serious feature of KD, it is not required for diagnosis.* ### **Analysis of Diagnostic Criteria (CRASH and Burn)** To diagnose Classic KD, a patient must have a **Fever for ≥5 days** plus **4 out of 5** of the following: 1. **C**onjunctivitis: Bilateral, bulbar, non-exudative (spares the limbus). 2. **R**ash: Polymorphous, non-vesicular. 3. **A**denopathy: Cervical, usually unilateral, >1.5 cm. 4. **S**trawbery tongue: Includes oropharyngeal erythema and cracked lips. 5. **H**and/Foot changes: Edema, erythema, or periungual desquamation. ### **High-Yield NEET-PG Pearls** * **Incomplete Kawasaki:** Diagnosed when a child has fever but <4 criteria, provided they have coronary artery abnormalities on Echo. * **Treatment:** IVIG (2g/kg) + High-dose Aspirin. This is the only pediatric condition where high-dose aspirin is used despite the risk of Reye’s Syndrome. * **Most Common Cause:** KD is the leading cause of acquired heart disease in children in developed nations. * **Cardiac Complication:** Coronary artery aneurysms typically appear in the subacute phase (weeks 2–4).

Question 194: What is the most common heart abnormality in children?

A. Atrial septal defect
B. Ventricular septal defect (Correct Answer)
C. Tetralogy of Fallot
D. Total anomalous pulmonary venous connection

Explanation: **Explanation:** **Ventricular Septal Defect (VSD)** is the most common congenital heart disease (CHD) in children, accounting for approximately **25–30%** of all cardiac malformations. It involves a hole in the interventricular septum, leading to a left-to-right shunt. While many small VSDs (especially muscular types) close spontaneously in early childhood, they remain the most frequently diagnosed abnormality at birth. **Analysis of Options:** * **Atrial Septal Defect (ASD):** While common, it is less frequent than VSD in children. However, it is the most common CHD diagnosed in **adults** because it often remains asymptomatic until later in life. * **Tetralogy of Fallot (TOF):** This is the most common **cyanotic** heart disease after infancy (beyond one year of age). Transposition of the Great Arteries (TGA) is the most common cyanotic CHD at birth. * **Total Anomalous Pulmonary Venous Connection (TAPVC):** This is a rare cyanotic heart disease characterized by pulmonary veins draining into the right atrium instead of the left. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type of VSD:** Membranous (Perimembranous) VSD. * **Most common CHD overall:** VSD. * **Most common CHD in Down Syndrome:** Atrioventricular Septal Defect (AVSD/Endocardial cushion defect). * **Most common CHD in Turner Syndrome:** Bicuspid Aortic Valve (followed by Coarctation of Aorta). * **Most common CHD in Congenital Rubella:** Patent Ductus Arteriosus (PDA). * **Auscultation:** VSD typically presents with a harsh **pansystolic murmur** best heard at the left lower sternal border.

Question 195: Which of the following are considered major criteria for Rheumatic fever?

A. Chorea
B. Erythema nodosum
C. Arthritis (Correct Answer)
D. Fever

Explanation: The diagnosis of Acute Rheumatic Fever (ARF) is based on the **Revised Jones Criteria (2015)**. These criteria are divided into Major and Minor manifestations. ### **Explanation of the Correct Answer** **C. Arthritis:** This is a **Major Criterion**. In low-risk populations, it typically presents as **Migratory Polyarthritis** (affecting large joints like the knees, ankles, elbows, and wrists). In high-risk populations (like India), even **Monoarthritis** or **Polyarthralgia** can be considered a major criterion under the 2015 revision. ### **Analysis of Incorrect Options** * **A. Chorea:** While **Sydenham’s Chorea** is a major criterion, the option simply states "Chorea." In the context of this specific question format, Arthritis is the most definitive and classic answer. (Note: In many exams, if both are present, Arthritis is the most common presenting major symptom). * **B. Erythema nodosum:** This is **not** a feature of Rheumatic Fever. The major skin manifestation of ARF is **Erythema Marginatum** (evanescent, non-pruritic, pink rings). Erythema nodosum is associated with conditions like Sarcoidosis, TB, or IBD. * **D. Fever:** This is a **Minor Criterion**. Other minor criteria include arthralgia, prolonged PR interval on ECG, and elevated acute phase reactants (ESR/CRP). ### **NEET-PG High-Yield Pearls** * **Mnemonic for Major Criteria (JONES):** **J**oints (Arthritis), **O** (Carditis - shaped like a heart), **N**odules (Subcutaneous), **E**rythema Marginatum, **S**ydenham Chorea. * **Requirements for Diagnosis:** 2 Major OR 1 Major + 2 Minor criteria, **PLUS** evidence of a preceding Group A Streptococcal (GAS) infection (e.g., elevated ASO titer, positive throat culture, or Rapid Antigen Test). * **Most Common Manifestation:** Arthritis. * **Most Serious Manifestation:** Carditis (can lead to permanent valvular damage, most commonly the Mitral Valve).

Question 196: A male child presented with cryptorchidism, mental retardation, and pulmonary stenosis. He has a normal karyotype. Which of the following is the diagnosis?

A. Noonan's syndrome (Correct Answer)
B. Turner's syndrome
C. Down's syndrome
D. Angelman's syndrome

Explanation: **Explanation:** The clinical presentation of **pulmonary stenosis**, **cryptorchidism**, and **intellectual disability** in a male child with a **normal karyotype** is a classic description of **Noonan’s Syndrome**. 1. **Why Noonan’s Syndrome is correct:** Often referred to as the "Male Turner Syndrome," Noonan’s syndrome is an autosomal dominant disorder (most commonly due to mutations in the *PTPN11* gene). While it shares phenotypic features with Turner syndrome (webbed neck, short stature, low-set ears, and cubitus valgus), it occurs in both males and females. Crucially, the karyotype is normal (46, XY or 46, XX). The most common cardiac lesion is **Pulmonary Valve Stenosis** (dysplastic valve), followed by Hypertrophic Cardiomyopathy (HCM). 2. **Why other options are incorrect:** * **Turner’s Syndrome (45, X):** Occurs only in females. The most common cardiac defects are **Bicuspid Aortic Valve** and **Coarctation of the Aorta**. * **Down’s Syndrome (Trisomy 21):** Characterized by distinct facies (up-slanting palpebral fissures, Simian crease). The most common cardiac defect is an **Atrioventricular Septal Defect (AVSD)**. * **Angelman’s Syndrome:** A neurodevelopmental disorder (deletion on maternal chromosome 15) characterized by "happy puppet" behavior, seizures, and severe intellectual disability, but it is not typically associated with pulmonary stenosis or cryptorchidism. **High-Yield Clinical Pearls for NEET-PG:** * **Noonan Syndrome:** Pulmonary Stenosis + Normal Karyotype + PTPN11 mutation. * **Turner Syndrome:** Coarctation of Aorta + 45, X Karyotype. * **Williams Syndrome:** Supravalvular Aortic Stenosis + "Elfin" facies + Hypercalcemia. * **Alagille Syndrome:** Peripheral Pulmonary Artery Stenosis + Bile duct paucity (jaundice) + Butterfly vertebrae.

Question 197: The term infantile polyarteritis nodosa was used for which of the following conditions?

A. Goodpasture syndrome
B. Henoch-Schonlein purpura
C. Kawasaki disease (Correct Answer)
D. Takayasu arteritis

Explanation: **Explanation:** **Kawasaki Disease (KD)** is an acute, febrile, medium-vessel vasculitis of childhood. Historically, before the condition was formally described by Tomisaku Kawasaki in 1967, cases involving coronary artery aneurysms and systemic vasculitis in infants were referred to as **Infantile Polyarteritis Nodosa (IPN)**. Pathologically, the vascular lesions in KD are nearly identical to those seen in Polyarteritis Nodosa (PAN), characterized by transmural inflammation and fibrinoid necrosis, leading to the historical nomenclature. **Analysis of Incorrect Options:** * **Goodpasture Syndrome:** This is an autoimmune condition characterized by anti-glomerular basement membrane (anti-GBM) antibodies affecting the lungs (alveolar hemorrhage) and kidneys (glomerulonephritis). It is not a systemic vasculitis. * **Henoch-Schonlein Purpura (IgA Vasculitis):** This is a small-vessel vasculitis characterized by the tetrad of palpable purpura, arthritis, abdominal pain, and renal involvement. It is the most common vasculitis in children but was never termed IPN. * **Takayasu Arteritis:** Known as "pulseless disease," this is a large-vessel vasculitis primarily affecting the aorta and its main branches. It typically presents in adolescent girls and young women. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Based on fever for ≥5 days plus 4 out of 5 criteria (Conjunctivitis, Rash, Edema/Erythema of hands/feet, Adenopathy, Mucositis/Strawberry tongue). * **Cardiac Complication:** Coronary artery aneurysms are the most serious complication (occurs in 20-25% of untreated cases). * **Treatment:** High-dose IVIG (2g/kg) and Aspirin. IVIG is most effective when given within the first 10 days of illness. * **Echo Schedule:** Perform at diagnosis, at 2 weeks, and at 6–8 weeks.

Question 198: Which of the following is NOT a major criterion for rheumatic fever?

A. Carditis
B. Arthritis
C. Sydenham chorea
D. ASO titer (Correct Answer)

Explanation: The diagnosis of Acute Rheumatic Fever (ARF) is based on the **Revised Jones Criteria**. To make a diagnosis, one requires evidence of a preceding Group A Streptococcal (GAS) infection plus either two major criteria or one major and two minor criteria. ### Why ASO Titer is the Correct Answer **ASO (Antistreptolysin O) titer** is not a major or minor criterion; rather, it serves as **essential evidence of a preceding Streptococcal infection**. While a positive ASO titer is necessary to support the diagnosis, it does not fulfill the clinical symptomatic requirements categorized under "Major" or "Minor" criteria. ### Explanation of Incorrect Options (Major Criteria) The major criteria are represented by the mnemonic **J♥NES**: * **Carditis (Option A):** Present in 50-70% of cases. It typically manifests as valvulitis (most commonly the mitral valve), leading to new-onset murmurs or heart failure. * **Arthritis (Option B):** Specifically "Migratory Polyarthritis." It involves large joints (knees, ankles, elbows) and is exquisitely responsive to salicylates. * **Sydenham Chorea (Option C):** Also known as "St. Vitus' Dance," these are involuntary, purposeless movements. It can occur after a long latent period and may be the sole manifestation of ARF. * *Note: The other two major criteria are **Erythema Marginatum** and **Subcutaneous Nodules**.* ### High-Yield Clinical Pearls for NEET-PG * **Minor Criteria:** Fever, Arthralgia (if arthritis is not used as a major criterion), prolonged PR interval on ECG, and elevated inflammatory markers (ESR/CRP). * **Exceptions:** Chorea and indolent carditis do not require evidence of preceding GAS infection for diagnosis. * **Most Common Valve Involved:** Mitral valve (Regurgitation in acute phase, Stenosis in chronic phase). * **Drug of Choice:** Penicillin is the gold standard for both treatment and secondary prophylaxis.

Question 199: 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 ocular hallmark of 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 feature 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:** * **Most Serious Complication:** Coronary artery aneurysms (occurs in 20-25% of untreated cases). * **Treatment:** High-dose IVIG (2g/kg) and Aspirin (to prevent coronary thrombosis). * **Incomplete Kawasaki:** Diagnosed when fever is present with <4 criteria but supportive lab findings (e.g., high ESR/CRP, sterile pyuria, or thrombocytosis) or echocardiographic abnormalities are found. * **Age Group:** Primarily affects children <5 years old.

Question 200: A 12-year-old child with a history of rheumatic heart disease presents with a one-month history of low-grade fever. She has pallor, splenomegaly, clubbing, and microscopic hematuria. What is the most important diagnostic test to perform?

A. Antistreptolysin O titer
B. C-reactive protein
C. Urine culture
D. Blood culture (Correct Answer)

Explanation: **Explanation:** The clinical presentation of a child with pre-existing **Rheumatic Heart Disease (RHD)** presenting with prolonged low-grade fever, splenomegaly, clubbing, and microscopic hematuria is a classic textbook description of **Infective Endocarditis (IE)**. In any patient with structural heart disease and unexplained fever, IE must be ruled out first. **Why Blood Culture is the correct answer:** Blood culture is the **"Gold Standard"** and a **Major Criterion** according to the **Modified Duke Criteria** for diagnosing IE. It identifies the causative organism and determines antibiotic sensitivity, which is critical for life-saving treatment. Microscopic hematuria in this patient (focal glomerulonephritis) and clubbing are peripheral "immunological phenomena" strongly suggestive of IE. **Why other options are incorrect:** * **ASO Titer:** This is used to diagnose a recent Group A Streptococcal infection (Acute Rheumatic Fever). While the patient has a history of RHD, the current subacute presentation points toward endocarditis, not a fresh episode of rheumatic fever. * **C-reactive Protein (CRP):** This is a non-specific marker of inflammation. While it will likely be elevated, it does not provide a definitive diagnosis or guide specific therapy. * **Urine Culture:** While the patient has hematuria, this is typically due to immune-complex mediated glomerulonephritis or embolic phenomena from the heart valves, not a primary urinary tract infection. **High-Yield Clinical Pearls for NEET-PG:** * **Modified Duke Criteria:** Diagnosis requires 2 Major, or 1 Major + 3 Minor, or 5 Minor criteria. * **Most common organism in IE (Overall):** *Staphylococcus aureus*. * **Most common organism in Subacute IE (Native valve):** *Viridans group Streptococci*. * **Echocardiography:** The other Major Criterion is the presence of vegetation, abscess, or new valvular regurgitation on Echo (TEE is more sensitive than TTE).

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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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Cardiology — MCQs

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