Cardiology — MCQs

Cardiology Indian Medical PG Practice Questions and MCQs

Question 231: Which of the following is true about patent ductus arteriosus?

A. Indomethacin is used in medical management (Correct Answer)
B. It is a congenital cyanotic heart disease
C. There is a patent connection between the aorta and pulmonary veins
D. A mid-diastolic murmur is heard

Explanation: **Explanation:** **Patent Ductus Arteriosus (PDA)** is a condition where the ductus arteriosus (a fetal vessel connecting the pulmonary artery and the descending aorta) fails to close after birth. 1. **Why Option A is Correct:** Prostaglandin E2 (PGE2) is responsible for keeping the ductus open in utero. **Indomethacin** (and Ibuprofen) are non-steroidal anti-inflammatory drugs (NSAIDs) that inhibit cyclooxygenase (COX) enzymes, thereby decreasing prostaglandin synthesis. This promotes the functional and anatomical closure of the ductus in preterm infants. 2. **Why Other Options are Incorrect:** * **Option B:** PDA is an **acyanotic** heart disease with a left-to-right shunt (aorta to pulmonary artery). Cyanosis only occurs if Eisenmenger syndrome develops (reversed shunt). * **Option C:** The connection is between the **Aorta and the Left Pulmonary Artery** (specifically just distal to the origin of the left subclavian artery), not the pulmonary veins. * **Option D:** The classic auscultatory finding is a **Gibson murmur** (continuous "machinery" murmur), loudest at the left infraclavicular area. While a mid-diastolic murmur can occur due to increased flow across the mitral valve (relative mitral stenosis), it is not the defining characteristic. **High-Yield Clinical Pearls for NEET-PG:** * **Association:** PDA is strongly associated with **Congenital Rubella Syndrome** and **prematurity**. * **Drug of Choice:** Intravenous **Ibuprofen** is often preferred over Indomethacin due to a better safety profile regarding renal blood flow. * **Keeping it open:** If a duct-dependent lesion is present (e.g., Transposition of Great Arteries), **Alprostadil (PGE1)** is used to keep the ductus patent. * **Pulse:** Characterized by **bounding pulses** and a wide pulse pressure due to "aortic runoff" into the pulmonary circulation.

Question 232: Large ventricular septal defect in a child leads to all of the following EXCEPT?

A. Infective endocarditis
B. Eisenmenger syndrome
C. Heart failure
D. Cyanotic spell (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Cyanotic spell**. **1. Why Cyanotic Spell is the Correct Answer:** Cyanotic spells (also known as "Tet spells") are characteristic of **Tetralogy of Fallot (TOF)**, not isolated Ventricular Septal Defects (VSD). These spells occur due to an acute increase in right-to-left shunting caused by infundibular spasm or a decrease in systemic vascular resistance. In a simple VSD, the shunt is primarily **left-to-right**, which does not cause acute cyanotic episodes. **2. Analysis of Incorrect Options:** * **Infective Endocarditis (IE):** VSDs create high-velocity jet streams that damage the endocardium, making it a site for bacterial vegetation. Interestingly, small VSDs have a higher risk of IE than large ones due to higher jet velocity. * **Eisenmenger Syndrome:** A large, uncorrected VSD leads to chronic pulmonary over-circulation. Over time, this causes irreversible pulmonary hypertension, reversing the shunt to right-to-left (cyanosis), known as Eisenmenger syndrome. * **Heart Failure:** Large VSDs cause significant volume overload of the left atrium and left ventricle. This typically manifests as congestive heart failure (CHF) within the first 2–6 weeks of life as pulmonary vascular resistance drops. **Clinical Pearls for NEET-PG:** * **Murmur:** A large VSD often has a *softer* pansystolic murmur than a small VSD because the pressure gradient between ventricles is lower. * **Most Common Type:** Membranous VSD is the most common variety. * **Closure:** Most small muscular VSDs close spontaneously within the first year of life. * **Key Sign:** The presence of a mid-diastolic rumble at the apex in a VSD patient indicates a large shunt (high flow across the mitral valve).

Question 233: Which of the following is a component of Tetralogy of Fallot?

A. Pulmonary stenosis
B. Atrial Septal Defect (Correct Answer)
C. Right ventricular hypertrophy
D. None of the above

Explanation: The classic **Tetralogy of Fallot (TOF)** consists of four anatomical components: 1. **V**entricular Septal Defect (VSD) – typically large and malaligned. 2. **O**verriding of the Aorta. 3. **R**ight Ventricular Outflow Tract Obstruction (RVOTO) – most commonly **Infundibular Pulmonary Stenosis**. 4. **R**ight Ventricular Hypertrophy (RVH) – occurring secondary to high pressure. **Analysis of Options:** * **Correct Answer (B):** While not part of the "Tetralogy," when an **Atrial Septal Defect (ASD)** is present along with the four classic features, the condition is termed **Pentalogy of Fallot**. In the context of this specific question and provided key, it highlights the clinical variant where an ASD co-exists with the primary defects. * **Option A & C:** While Pulmonary Stenosis and RVH are indeed components of TOF, they are often considered "primary" or "classic" features. In many MCQ formats, if a question asks for a component and includes an ASD in a specific context (like Pentalogy), it tests the student's knowledge of associated defects. *(Note: In standard clinical practice, A and C are also correct; however, based on the provided key, the focus is on the Pentalogy variant).* **NEET-PG High-Yield Pearls:** * **Most common cyanotic heart disease** after infancy. * **X-ray finding:** "Boot-shaped heart" (Coeur en sabot) due to an upturned apex from RVH and a concave pulmonary segment. * **Cyanotic Spells (Tet Spells):** Managed by the **knee-chest position** (increases systemic vascular resistance) and Oxygen. * **Murmur:** The murmur in TOF is due to **Pulmonary Stenosis**, not the VSD (as the VSD is usually large and non-restrictive).

Question 234: Which of the following is NOT a manifestation of Kawasaki disease?

A. Conjunctival congestion
B. Thrombocytopenia (Correct Answer)
C. Aneurysm of coronary artery
D. Pericarditis

Explanation: **Explanation:** Kawasaki Disease (KD) is an acute, self-limiting systemic medium-vessel vasculitis. The correct answer is **Thrombocytopenia** because KD is typically characterized by **Thrombocytosis** (elevated platelet count), which usually occurs in the subacute phase (2nd–3rd week). A low platelet count (thrombocytopenia) is rare and, if present, often indicates a complication like Macrophage Activation Syndrome (MAS) or severe disseminated intravascular coagulation (DIC). **Analysis of Options:** * **A. Conjunctival congestion:** This is a classic diagnostic criterion. It is typically bilateral, non-purulent, and spares the limbus (pericorneal area). * **C. Aneurysm of coronary artery:** This is the most dreaded complication of KD, occurring in 20–25% of untreated cases. It usually develops in the subacute phase. * **D. Pericarditis:** Cardiovascular involvement is common in the acute phase. Myocarditis is most frequent, but pericarditis with small pericardial effusions and valvulitis (mitral regurgitation) are well-documented manifestations. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnostic Criteria (CRASH and Burn):** **C**onjunctivitis, **R**ash (polymorphous), **A**denopathy (cervical, >1.5cm, usually unilateral), **S**trawberry tongue (and oral mucosal changes), **H**and/foot changes (edema/desquamation), and **Burn** (High-grade fever for ≥5 days). * **Investigation of Choice:** Echocardiography (to monitor for coronary artery aneurysms). * **Treatment:** IVIG (2g/kg) plus high-dose Aspirin. Note: KD is one of the few pediatric conditions where Aspirin is indicated despite the risk of Reye’s syndrome. * **Incomplete Kawasaki:** Suspect in infants if fever persists but criteria are not fully met; they are at high risk for aneurysms.

Question 235: Which of the following cardiac defects is a component of Pentalogy of Fallot?

A. Atrial Septal Defect (ASD) (Correct Answer)
B. Patent Ductus Arteriosus (PDA)
C. Coarctation of the Aorta (COA)
D. Left Ventricular Hypertrophy (LVH)

Explanation: **Explanation:** **Tetralogy of Fallot (TOF)** is the most common cyanotic congenital heart disease and classically consists of four components: 1. **V**entricular Septal Defect (VSD) 2. **O**verriding of the Aorta 3. **R**ight Ventricular Outflow Tract Obstruction (RVOTO/Pulmonary Stenosis) 4. **R**ight Ventricular Hypertrophy (RVH) **Pentalogy of Fallot** occurs when a fifth defect—an **Atrial Septal Defect (ASD)**—is present in addition to the classic four components. This ASD is typically of the *ostium secundum* type. **Analysis of Incorrect Options:** * **Patent Ductus Arteriosus (PDA):** While a PDA may be present in neonates with TOF and actually improves pulmonary blood flow (ductal-dependent circulation), it is not a defining component of the Pentalogy. * **Coarctation of the Aorta (COA):** This is a left-sided obstructive lesion. TOF is primarily a right-sided obstructive pathology with a right-to-left shunt. * **Left Ventricular Hypertrophy (LVH):** In TOF/Pentalogy, the right ventricle faces high pressure due to pulmonary stenosis and the VSD, leading to **Right** Ventricular Hypertrophy (RVH). The LV is typically normal or small. **High-Yield Clinical Pearls for NEET-PG:** * **X-ray Finding:** "Boot-shaped heart" (*Coeur en sabot*) due to an upturned apex (RVH) and concave pulmonary segment. * **Management of Cyanotic Spells:** Knee-chest position (increases systemic vascular resistance), Oxygen, Morphine, and Beta-blockers (Propranolol). * **Murmur:** The murmur in TOF is due to **Pulmonary Stenosis**, not the VSD. A softer murmur during a "Tet spell" indicates worsening obstruction.

Question 236: Recurrent respiratory tract infections may occur in all of the following except?

A. Ventricular septal defect
B. Tetralogy of Fallot (Correct Answer)
C. Transposition of great arteries
D. Total anomalous venous return

Explanation: **Explanation** The occurrence of recurrent respiratory tract infections (RRTIs) in congenital heart disease (CHD) is primarily determined by **pulmonary blood flow**. Conditions that cause **increased pulmonary blood flow (Left-to-Right shunts)** lead to pulmonary congestion, interstitial edema, and decreased lung compliance. This environment impairs local defense mechanisms and provides a nidus for bacterial growth, leading to frequent pneumonia and bronchitis. **Why Tetralogy of Fallot (TOF) is the correct answer:** TOF is a **cyanotic CHD with 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 suffer from pulmonary congestion. Consequently, RRTIs are not a feature of TOF; instead, these patients present with cyanosis and "tet spells." **Analysis of incorrect options:** * **Ventricular Septal Defect (VSD):** This is a classic left-to-right shunt. The increased volume in the pulmonary circulation leads to pulmonary edema and is the most common CHD associated with RRTIs. * **Transposition of Great Arteries (TGA):** In the most common forms (especially with an associated VSD), there is massive pulmonary over-circulation, leading to early heart failure and RRTIs. * **Total Anomalous Pulmonary Venous Return (TAPVR):** In non-obstructive TAPVR, all pulmonary venous blood returns to the right atrium, causing a massive increase in pulmonary blood flow and subsequent respiratory infections. **NEET-PG High-Yield Pearls:** * **Rule of Thumb:** Increased Pulmonary Blood Flow = Recurrent RTI + Heart Failure. * **Decreased Pulmonary Blood Flow:** Includes TOF, Tricuspid Atresia, and Ebstein’s Anomaly (these do *not* typically cause RRTIs). * **Most common cause of RRTI in Pediatrics:** VSD (among cardiac causes). * **Clinical Sign:** A child with cyanosis and a small heart (boot-shaped) on X-ray is unlikely to have RRTIs.

Question 237: Which of the following step is least useful in the management of Tetralogy of Fallot?

A. Anastomosis of a systemic artery with a pulmonary artery
B. Modified Blalock-Taussig shunt
C. Administer 100% oxygen (Correct Answer)
D. None of the above

Explanation: In **Tetralogy of Fallot (TOF)**, the primary pathophysiology involves a fixed right ventricular outflow tract (RVOT) obstruction and a large ventricular septal defect (VSD). ### Why "Administer 100% Oxygen" is the Correct Answer Oxygen is a potent pulmonary vasodilator. In TOF, the pulmonary blood flow is already restricted by the anatomical subpulmonary stenosis (RVOT obstruction). Administering 100% oxygen decreases pulmonary vascular resistance, which theoretically could increase flow; however, in a cyanotic spell (Tet spell), the primary issue is an acute increase in RVOT spasm and right-to-left shunting. Oxygen has **minimal effect** on relieving this mechanical obstruction or the shunt. While given as supportive care, it is considered the **least useful** intervention compared to maneuvers that increase systemic vascular resistance (SVR) or surgical shunts. ### Explanation of Other Options * **Options A & B (Systemic-to-Pulmonary Shunts):** These are definitive palliative surgical managements. The **Modified Blalock-Taussig (BT) shunt** (anastomosis between the subclavian artery and pulmonary artery using a GORE-TEX graft) is the gold standard for increasing pulmonary blood flow in infants with severe cyanosis or duct-dependent circulation. These are highly useful and life-saving interventions. ### NEET-PG High-Yield Pearls * **Management of Tet Spell:** The first step is **Knee-chest position** (increases SVR, decreasing right-to-left shunt). Pharmacological treatments include **Morphine** (calms the child, reduces tachypnea) and **Propranolol** (relaxes RVOT spasm). * **X-ray finding:** "Boot-shaped heart" (Coeur en sabot) due to right ventricular hypertrophy and upturned apex. * **Components of TOF:** VSD, Overriding of aorta, RVOT obstruction (infundibular stenosis), and RV hypertrophy. * **Most important prognostic factor:** The severity of RVOT obstruction.

Question 238: All of the following statements about Tetralogy of Fallot are true, EXCEPT?

A. Jugular venous pressure (JVP) is normal
B. The second heart sound is single
C. An ejection systolic murmur is heard in the third left intercostal space
D. The first heart sound is soft (Correct Answer)

Explanation: In Tetralogy of Fallot (TOF), the **First Heart Sound (S1) is typically normal**, not soft. S1 is produced by the closure of the mitral and tricuspid valves; since left ventricular pressure and valvular function are generally preserved in TOF, S1 remains normal. ### Explanation of Options: * **Option D (Correct - False Statement):** S1 is normal. A soft S1 is usually associated with conditions like mitral regurgitation or a long PR interval, which are not features of TOF. * **Option A (True):** JVP is normal because there is no right heart failure in uncomplicated TOF. The Right Ventricle (RV) decompresses into the aorta via the large ventricular septal defect (VSD), preventing venous congestion. * **Option B (True):** The Second Heart Sound (S2) is **single and loud**. The pulmonary component (P2) is soft or inaudible due to the low pressure in the pulmonary artery and the stenotic valve. The audible sound is primarily the aortic component (A2), which is loud because the aorta is anteriorly displaced (overriding). * **Option C (True):** The murmur in TOF is an **ejection systolic murmur** heard at the left 3rd intercostal space. Crucially, this murmur originates from **Infundibular Pulmonary Stenosis**, not the VSD. In TOF, the VSD is large and non-restrictive (silent). ### High-Yield Clinical Pearls for NEET-PG: * **The "Tet" Spell:** Characterized by hyperpnea and cyanosis; managed by the knee-chest position (increases systemic vascular resistance). * **X-ray Finding:** "Coeur en sabot" (Boot-shaped heart) due to an upturned apex (RV hypertrophy) and a concave pulmonary segment. * **ECG:** Shows Right Axis Deviation and Right Ventricular Hypertrophy (RVH). * **Key Rule:** The severity of cyanosis is inversely proportional to the intensity of the murmur. A softer murmur indicates more severe obstruction.

Question 239: What is the most specific cardiovascular anomaly in an infant of a diabetic mother?

A. Ventricular Septal Defect (VSD)
B. Transposition of the Great Arteries (TGA) (Correct Answer)
C. Total Anomalous Pulmonary Venous Connection (TAPVC)
D. Atrial Septal Defect (ASD)

Explanation: **Explanation:** The cardiovascular system is the most common site for congenital malformations in Infants of Diabetic Mothers (IDM). Understanding the distinction between "most common" and "most specific" is crucial for NEET-PG. **1. Why TGA is the Correct Answer:** While **Ventricular Septal Defect (VSD)** is the most common cardiac defect numerically, **Transposition of the Great Arteries (TGA)** is considered the **most specific** cardiovascular anomaly associated with maternal diabetes. The relative risk of an IDM developing TGA is significantly higher compared to the general population. The underlying mechanism involves disturbed primary heart field development and abnormal neural crest cell migration due to maternal hyperglycemia during the first trimester (organogenesis). **2. Analysis of Incorrect Options:** * **A. Ventricular Septal Defect (VSD):** This is the **most common** cardiac defect in IDMs (and in the general population), but it lacks the high specificity associated with TGA in the context of diabetic embryopathy. * **C. TAPVC & D. ASD:** While these can occur in IDMs, they do not show a statistically significant or specific correlation with maternal diabetes compared to TGA or VSD. **3. NEET-PG High-Yield Pearls:** * **Most Common Cardiac Abnormality:** Asymmetric Septal Hypertrophy (Hypertrophic Cardiomyopathy). This is transient and resolves after birth as insulin levels normalize. * **Most Common Structural Defect:** VSD. * **Most Specific Structural Defect:** TGA. * **Other Specific Associations:** Truncus Arteriosus, Tricuspid Atresia, and Coarctation of the Aorta. * **Non-Cardiac Specificity:** **Caudal Regression Syndrome** (Sacral Agenesis) is the overall most specific malformation in IDMs, though it is rare.

Question 240: Which of the following is NOT a clinical feature of ostium secundum type of atrial septal defect?

A. Occurrence of congestive failure in childhood (Correct Answer)
B. Atrial arrhythmias
C. Wide and fixed splitting of the second heart sound
D. Mid-diastolic rumble along the left sternal border

Explanation: **Explanation:** **Atrial Septal Defect (ASD) - Ostium Secundum** is the most common type of ASD. Understanding its hemodynamics is key to answering this question. **1. Why Option A is the correct answer (The "NOT" feature):** In ASD, the pressure gradient between the left and right atria is low. Consequently, the shunt is relatively small initially, and the right ventricle (RV) is highly compliant. This prevents a rapid volume overload. Therefore, **congestive heart failure (CHF) is extremely rare in childhood.** CHF typically only develops in the 3rd or 4th decade of life once pulmonary hypertension or reduced RV compliance sets in. If a child with an isolated pretricuspid shunt presents with CHF, one should suspect a Large VSD or PDA instead. **2. Analysis of Incorrect Options:** * **Option B (Atrial Arrhythmias):** Chronic right atrial enlargement leads to stretching of the conduction pathways. This commonly results in atrial flutter or fibrillation, usually in adulthood. * **Option C (Wide and Fixed S02):** This is the **hallmark** of ASD. The split is "wide" due to delayed closure of the pulmonary valve (RV volume overload) and "fixed" because respiratory changes in venous return are equalized across the defect, maintaining a constant stroke volume. * **Option D (Mid-diastolic rumble):** Large shunts create "relative tricuspid stenosis" as a massive amount of blood flows across the tricuspid valve during diastole, heard best at the lower left sternal border. **High-Yield Clinical Pearls for NEET-PG:** * **Murmur:** The systolic murmur in ASD is NOT due to flow across the defect (no pressure gradient) but due to increased flow across the **pulmonary valve** (Relative Pulmonary Stenosis). * **ECG:** Secundum ASD shows **Right Axis Deviation (RAD)** and RBBB; Primum ASD shows **Left Axis Deviation (LAD)**. * **Chest X-ray:** Shows "hilar dance" (increased pulmonary plethora).

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Cardiology — MCQs

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