Cardiology — MCQs

Cardiology Indian Medical PG Practice Questions and MCQs

Question 221: Which of the following is NOT a characteristic feature of Kawasaki disease?

A. Cervical lymphadenopathy
B. Bilateral conjunctivitis
C. Rash
D. Bald tongue (Correct Answer)

Explanation: **Explanation:** Kawasaki Disease (KD) is an acute, febrile, medium-vessel vasculitis that primarily affects children under five years of age. The diagnosis is clinical, based on the presence of high-grade fever for at least 5 days plus four out of five principal clinical features. **Why "Bald Tongue" is the correct answer:** In Kawasaki Disease, the characteristic oral finding is a **"Strawberry Tongue"** (erythema and prominent fungiform papillae), not a "Bald Tongue." A bald, smooth, or atrophic tongue is typically associated with nutritional deficiencies (such as Vitamin B12, Folate, or Iron deficiency) or certain types of glossitis, but it is not a feature of the acute inflammatory phase of KD. **Analysis of Incorrect Options:** * **Cervical lymphadenopathy:** This is one of the five diagnostic criteria. It is usually unilateral, non-fluctuant, and involves at least one node >1.5 cm in diameter. * **Bilateral conjunctivitis:** This is a classic feature. It is typically non-purulent (no discharge) and spares the limbus (the area around the iris). * **Rash:** A polymorphous exanthema (often maculopapular) usually appears on the trunk and extremities within five days of fever onset. **High-Yield Clinical Pearls for NEET-PG:** * **CRASH and Burn Mnemonic:** **C**onjunctivitis, **R**ash, **A**denopathy, **S**trawberry tongue, **H**and/foot changes (edema/desquamation), and **Burn** (Fever >5 days). * **Most Serious Complication:** Coronary artery aneurysms (occurs in 20-25% of untreated cases). * **Treatment:** High-dose IVIG (2g/kg) and Aspirin. Note: This is one of the few pediatric conditions where Aspirin is indicated despite the risk of Reye’s syndrome. * **Echocardiography:** Should be performed at diagnosis, at 2 weeks, and at 6-8 weeks to monitor for coronary involvement.

Question 222: All the following are indicated in the long-term therapy of children with coronary abnormalities in Kawasaki disease EXCEPT?

A. Intravenous immunoglobulins (Correct Answer)
B. Aspirin
C. Clopidogrel
D. Warfarin

Explanation: **Explanation:** The management of Kawasaki Disease (KD) is divided into two phases: **Acute Phase** (to reduce systemic inflammation and prevent coronary artery aneurysms) and **Long-term Phase** (to prevent thrombosis in damaged coronary arteries). **Why Intravenous Immunoglobulins (IVIG) is the correct answer:** IVIG is the cornerstone of **acute management**. It is administered as a single high dose (2 g/kg) within the first 10 days of illness to reduce the incidence of coronary artery abnormalities from 25% to <5%. However, IVIG has a short half-life and no role in the **long-term therapy** of established coronary abnormalities, which focuses on anti-thrombotic prophylaxis. **Analysis of Incorrect Options (Long-term therapies):** * **B. Aspirin:** Used in low doses (3–5 mg/kg/day) for its anti-platelet effect in all children with KD until coronary arteries are normal on echocardiography (usually 6–8 weeks) or indefinitely if abnormalities persist. * **C. Clopidogrel:** Added as dual anti-platelet therapy (DAPT) in children at high risk for thrombosis (e.g., rapidly expanding or large aneurysms). * **D. Warfarin:** Indicated for systemic anticoagulation in patients with **Giant Aneurysms** (internal diameter >8 mm or Z-score ≥10) to prevent myocardial infarction. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** KD is a clinical diagnosis (Fever ≥5 days + 4/5 clinical criteria: Conjunctivitis, Rash, Edema/Erythema of hands/feet, Mucosal changes, Cervical lymphadenopathy). * **Echo Timing:** Perform at diagnosis, 2 weeks, and 6–8 weeks. * **Vaccination:** Live vaccines (MMR, Varicella) should be delayed for **11 months** after high-dose IVIG administration. * **Reye Syndrome:** Avoid Ibuprofen if the child is on Aspirin; switch to Clopidogrel if the child develops Influenza or Varicella.

Question 223: A 4-month-old infant is brought to the physician for a routine examination. Physical examination shows epicanthic folds and a palmar simian crease. Cytogenetic testing shows an autosomal trisomy. Which of the following cardiac anomalies is most commonly associated with this condition?

A. Atrial septal defect
B. Complete Atrioventricular septal defect (Correct Answer)
C. Mitral stenosis
D. Patent ductus arteriosus

Explanation: ### Explanation **Diagnosis and Association** The clinical presentation of **epicanthic folds**, a **palmar simian crease**, and **autosomal trisomy** confirms a diagnosis of **Down Syndrome (Trisomy 21)**. Down syndrome is the most common chromosomal disorder associated with congenital heart disease (CHD), occurring in approximately 40–50% of affected infants. **Why Option B is Correct** The most common cardiac anomaly in Down syndrome is an **Atrioventricular Septal Defect (AVSD)**, specifically the **complete** form (also known as an Endocardial Cushion Defect). This defect involves a large hole in the center of the heart affecting both the atrial and ventricular septa, along with a common AV valve. It accounts for nearly 40% of all CHD cases in these patients. **Why Other Options are Incorrect** * **A. Atrial Septal Defect (ASD):** While Secundum ASDs are common in the general population and can occur in Down syndrome, they are less frequent than AVSDs in this specific population. (Note: Primum ASD is a component of partial AVSD). * **C. Mitral Stenosis:** This is not a classic association with Trisomy 21. Mitral valve abnormalities in Down syndrome are usually part of the complex AVSD morphology (e.g., a cleft mitral valve). * **D. Patent Ductus Arteriosus (PDA):** PDA is most strongly associated with **Congenital Rubella Syndrome** or prematurity, rather than Trisomy 21. **NEET-PG High-Yield Pearls** * **Most common CHD in Down Syndrome:** AVSD (Endocardial Cushion Defect). * **Second most common CHD in Down Syndrome:** Ventricular Septal Defect (VSD). * **ECG Finding in AVSD:** "Superior" or **Left Axis Deviation** with a "Goose-neck deformity" on angiography. * **Screening:** All infants with Down syndrome must receive an echocardiogram, regardless of whether a murmur is present, due to the high risk of asymptomatic CHD.

Question 224: Acute febrile illness with vasculitis having predilection for the coronary arteries is seen in:

A. Kawasaki disease (Correct Answer)
B. Adenovirus infection
C. Diphtheria
D. Measles

Explanation: ### Explanation **Correct Answer: A. Kawasaki Disease** **Medical Concept:** Kawasaki Disease (KD) is an **acute, self-limiting systemic medium-vessel vasculitis** of unknown etiology, primarily affecting children under 5 years of age. Its hallmark is a predilection for the **coronary arteries**, leading to coronary artery aneurysms (CAA) in approximately 25% of untreated cases. The pathogenesis involves pan-vasculitis with infiltration of inflammatory cells into the vessel wall, leading to structural weakening and dilation. **Analysis of Incorrect Options:** * **B. Adenovirus infection:** While adenovirus can mimic KD (fever, conjunctivitis, rash), it is a viral infection, not a primary vasculitis, and does not typically cause coronary artery pathology. * **C. Diphtheria:** This is a bacterial infection caused by *Corynebacterium diphtheriae*. Its primary cardiac complication is **toxic myocarditis** (due to exotoxin), not coronary vasculitis. * **D. Measles:** A viral illness characterized by the "3 Cs" (Cough, Coryza, Conjunctivitis) and Koplik spots. While it causes a rash and fever, it does not involve vasculitis of the coronary arteries. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnostic Criteria (CRASH and Burn):** Fever for ≥5 days + 4 out of 5: **C**onjunctivitis (bilateral, non-purulent), **R**ash (polymorphous), **A**denopathy (cervical, usually unilateral), **S**trawbery tongue (and oral mucosal changes), **H**ands/feet (edema, erythema, or periungual desquamation). * **Investigation of Choice:** 2D-Echocardiography (to monitor for coronary aneurysms). * **Treatment:** High-dose **IVIG** (2g/kg) and **Aspirin**. IVIG is most effective when given within the first 10 days to prevent CAAs. * **Incomplete Kawasaki:** Suspect in infants with prolonged fever who do not meet full criteria; they are at high risk for coronary complications.

Question 225: Turner syndrome is most commonly associated with which of the following?

A. Sacral agenesis
B. Coarctation of the aorta (Correct Answer)
C. Ventricular septal defect
D. Atrial septal defect

Explanation: **Explanation:** **Turner Syndrome (45, XO)** is a common chromosomal anomaly in females characterized by short stature, streak ovaries, and webbed neck. Cardiovascular malformations occur in approximately 25–50% of these patients. **Why Option B is Correct:** The most common specific cardiac lesion associated with Turner syndrome is **Bicuspid Aortic Valve (BAV)**, occurring in up to 30% of cases. However, among the options provided, **Coarctation of the Aorta (CoA)** is the classic and most frequently associated defect (seen in 10–15% of cases). The underlying mechanism is often related to lymphatic obstruction during fetal development, which alters hemodynamics in the developing heart. **Why Other Options are Incorrect:** * **A. Sacral agenesis:** This is the hallmark skeletal deformity associated with **Maternal Diabetes** (Caudal Regression Syndrome), not Turner syndrome. * **C. Ventricular septal defect (VSD):** While VSD is the most common congenital heart disease (CHD) overall, it is not specifically or characteristically associated with Turner syndrome. * **D. Atrial septal defect (ASD):** ASD is more commonly associated with **Holt-Oram syndrome** or **Down syndrome** (though AVSD is more specific for Down). **High-Yield Clinical Pearls for NEET-PG:** * **Most common cardiac lesion:** Bicuspid Aortic Valve (BAV). * **Most common associated defect (if BAV is not listed):** Coarctation of the Aorta (Pre-ductal type). * **Karyotype:** 45, XO is the most common; however, mosaicism (45,X/46,XX) can occur. * **Other associations:** Horseshoe kidney, wide-spaced nipples (shield chest), and increased risk of aortic dissection. * **Noonan Syndrome:** Often called "Male Turner," but it is autosomal dominant and most commonly associated with **Pulmonary Valve Stenosis**.

Question 226: In atrial septal defect, what is the typical state of the aorta?

A. Small (Correct Answer)
B. Normal
C. Enlarged
D. Aneurysmal

Explanation: **Explanation:** In **Atrial Septal Defect (ASD)**, the underlying pathophysiology is a left-to-right shunt at the atrial level. This leads to a volume overload of the right side of the heart (Right Atrium and Right Ventricle) and the pulmonary circulation. **Why the Aorta is Small:** Because a significant portion of the blood that enters the left atrium is shunted across the defect into the right atrium, the volume of blood passing into the Left Ventricle (LV) is reduced. Since the **Stroke Volume** of the LV is decreased, the **ascending aorta receives less blood**, leading to a characteristically **small or hypoplastic aortic knuckle** on a chest X-ray. **Analysis of Incorrect Options:** * **Normal:** While the aorta may appear "relatively" normal in very small, hemodynamically insignificant ASDs, the classic teaching for exams is that it is small due to the chronic reduction in systemic output. * **Enlarged/Aneurysmal:** These are incorrect because there is no hemodynamic reason for the aorta to dilate. Enlargement of the great vessels in ASD is seen in the **Pulmonary Artery**, not the aorta, due to increased pulmonary blood flow. **High-Yield Clinical Pearls for NEET-PG:** * **Radiological Triad of ASD:** 1. Right atrial and ventricular enlargement (Cardiomegaly), 2. Prominent pulmonary artery segment with pulmonary plethora, 3. **Small aortic knuckle.** * **Auscultation:** Characterized by a **wide, fixed split S2** and a mid-systolic flow murmur in the pulmonary area. * **ECG Findings:** Right axis deviation and RSR' pattern in V1 (Partial RBBB) are common. * **Most Common Type:** Ostium secundum is the most common variety of ASD.

Question 227: Ductus-dependent congenital heart lesions are a type of:

A. Distributive shock
B. Obstructive shock (Correct Answer)
C. Hypovolemic shock
D. Cardiogenic shock

Explanation: **Explanation:** **Ductus-dependent congenital heart lesions** (such as Coarctation of the aorta, Hypoplastic Left Heart Syndrome, or Critical Pulmonary Stenosis) rely on a patent ductus arteriosus (PDA) to maintain either systemic or pulmonary blood flow. When the ductus begins to close shortly after birth, there is a physical impedance to blood flow. In systemic lesions, the closure causes a mechanical blockage to the left ventricular outflow, leading to a sudden drop in cardiac output and systemic perfusion. This physical obstruction to the flow of blood defines **Obstructive Shock**. **Why other options are incorrect:** * **Distributive Shock:** Caused by excessive vasodilation and capillary leak (e.g., Sepsis, Anaphylaxis). In ductal lesions, the primary issue is a mechanical block, not a loss of vascular tone. * **Hypovolemic Shock:** Results from a loss of intravascular volume (e.g., hemorrhage or dehydration). Infants with ductal lesions have normal or even increased fluid volume but cannot circulate it effectively. * **Cardiogenic Shock:** While ductal closure eventually leads to heart failure, the primary mechanism is the "obstruction" to the outflow tract. Cardiogenic shock typically refers to primary pump failure (e.g., myocarditis or arrhythmias). **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** A neonate presenting with sudden collapse, metabolic acidosis, and absent femoral pulses between day 3 and day 10 of life (when the PDA closes). * **Management:** The immediate life-saving treatment is an infusion of **Prostaglandin E1 (Alprostadil)** to keep the ductus open. * **Differential:** Always consider ductal-dependent lesions in any neonate suspected of "sepsis" who does not respond to fluids and antibiotics.

Question 228: What is the commonest cause of systemic hypertension in children?

A. Coarctation of the aorta
B. Acute glomerulonephritis (Correct Answer)
C. Nephrotic syndrome
D. Congenital adrenal hyperplasia

Explanation: **Explanation:** In the pediatric population, the etiology of hypertension is predominantly **secondary** (identifiable cause), unlike adults where primary (essential) hypertension is more common. **1. Why Acute Glomerulonephritis (AGN) is correct:** Renal parenchymal disease is the leading cause of secondary hypertension in children. Among these, **Acute Post-Streptococcal Glomerulonephritis (PSGN)** is the most common cause of acute onset hypertension. The underlying mechanism is **fluid and sodium retention** due to a decreased Glomerular Filtration Rate (GFR) and activation of the Renin-Angiotensin-Aldosterone System (RAAS), leading to volume overload. **2. Analysis of Incorrect Options:** * **Coarctation of the Aorta:** This is the most common **cardiovascular** cause of hypertension in children, but it is less frequent overall than renal causes. It typically presents with upper limb hypertension and diminished lower limb pulses. * **Nephrotic Syndrome:** Hypertension is not a hallmark of "pure" nephrotic syndrome (like Minimal Change Disease). While it can occur in certain variants (like FSGS), it is far less common than in nephritic syndromes like AGN. * **Congenital Adrenal Hyperplasia (CAH):** Only specific types (11β-hydroxylase and 17α-hydroxylase deficiency) cause hypertension due to mineralocorticoid excess. These are rare endocrine causes. **Clinical Pearls for NEET-PG:** * **Rule of Thumb:** The younger the child and the higher the blood pressure, the more likely it is to be a secondary cause. * **Most common cause overall (Children):** Renal Parenchymal Disease (e.g., AGN, scarring). * **Most common cause in Neonates:** Renal artery thrombosis (often secondary to umbilical artery catheterization). * **Most common cause of "Sustained" Hypertension:** Renal artery stenosis or Coarctation.

Question 229: A child presents with a rare cyanotic congenital heart disease with diminished pulmonary blood flow due to an abnormality of the tricuspid valve. Which of the following is found in this cardiac condition?

A. Right ventricular dilatation
B. Right atrial dilatation (Correct Answer)
C. Left ventricular dilatation
D. Left atrial dilatation

Explanation: **Explanation:** The clinical presentation describes **Ebstein’s Anomaly**, a rare cyanotic congenital heart disease characterized by the downward displacement of the septal and posterior leaflets of the tricuspid valve into the right ventricle. **1. Why Right Atrial Dilatation is Correct:** In Ebstein’s anomaly, the displacement of the tricuspid valve "atrializes" a portion of the right ventricle. This results in a functional right ventricle that is very small and a **massive enlargement of the right atrium**. The tricuspid valve is usually regurgitant, further increasing the volume load on the right atrium, leading to its significant dilatation (often causing a "box-shaped" heart on X-ray). **2. Why the other options are incorrect:** * **Right Ventricular Dilatation:** The functional right ventricle is actually **small or hypoplastic** because a large part of it has been incorporated into the atrium. * **Left Ventricular/Atrial Dilatation:** These are not primary features. In fact, the massive right heart enlargement can compress the left ventricle (interventricular septal bulge), potentially reducing its filling, but it does not typically cause dilatation. **High-Yield Clinical Pearls for NEET-PG:** * **Auscultation:** Characterized by a "multi-click" sound or "sail sound" (loud T1) and a quadruple gallop rhythm. * **ECG:** Look for "Himalayan P waves" (giant right atrial waves) and often associated Wolff-Parkinson-White (WPW) syndrome. * **X-ray:** Massive cardiomegaly with a **"Box-shaped heart"** and decreased pulmonary vascular markings (oligemic lung fields). * **Maternal Link:** Classically associated with maternal **Lithium** intake during pregnancy.

Question 230: What is true about Atrial Septal Defect (ASD)?

A. The foramen ovale is patent.
B. A left parasternal heeve is due to increased pulmonary artery flow. (Correct Answer)
C. S2 is wide and fixed.
D. A systolic murmur is due to rapid flow of blood across the shunt.

Explanation: **Explanation:** In **Atrial Septal Defect (ASD)**, the primary pathophysiology involves a left-to-right shunt at the atrial level, leading to **volume overload of the right heart** (Right Atrium and Right Ventricle). 1. **Why Option B is Correct:** The increased volume of blood in the right ventricle is ejected into the pulmonary artery. This high-volume, high-pressure ejection causes a **left parasternal heave** (also known as a right ventricular heave). This physical finding is a direct clinical manifestation of right ventricular enlargement and hyperdynamic circulation in the pulmonary circuit. 2. **Why other options are incorrect:** * **Option A:** A **Patent Foramen Ovale (PFO)** is a flap-like opening that fails to fuse after birth; it is technically distinct from a true ASD (which involves an actual deficiency of septal tissue). * **Option C:** While S2 is indeed **wide and fixed** in ASD, the question asks for "what is true" based on the provided key. In many competitive exams, if multiple clinical features are present, the one describing the physical examination finding related to ventricular dynamics (heave) is often prioritized, though C is a classic hallmark. *(Note: In standard clinical teaching, C is also a defining feature of ASD).* * **Option D:** The systolic murmur in ASD is **not** due to flow across the shunt (the pressure gradient between atria is too low). Instead, it is a **crescendo-decrescendo systolic ejection murmur** heard at the left upper sternal border due to increased flow across the **pulmonary valve** (functional pulmonary stenosis). **High-Yield Clinical Pearls for NEET-PG:** * **Most common type:** Ostium Secundum (located in the region of the fossa ovalis). * **Auscultation:** Wide, fixed split S2 + Mid-systolic flow murmur at the pulmonary area + Mid-diastolic flow rumble at the tricuspid area (in large shunts). * **ECG Findings:** Right axis deviation and RSR' pattern in V1 (incomplete RBBB). * **Complication:** Paradoxical embolism is a known risk. Unlike VSD, Eisenmenger syndrome occurs much later in life (3rd–4th decade).

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Myocarditis and Cardiomyopathies

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Heart Failure in Children

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Cardiology — MCQs

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