Cardiology Practice Questions

Q: A child with large perimembranous VSD has congestive heart failure. Over time, the child shows clinical improvement in heart failure symptoms despite persistence of the defect. What is the most likely explanation?

Vascular changes in pulmonary circulation. ***Vascular changes in pulmonary circulation*** - The development of severe **pulmonary hypertension** and subsequent **pulmonary vascular obstructive disease** (Eisenmenger syndrome) can lead to a decrease in the left-to-right shunt. - As pulmonary vascular resistance approaches or exceeds systemic vascular resistance, the shunt lessens or reverses, reducing pulmonary blood flow and, paradoxically, improving symptoms of **congestive heart failure** related to pulmonary overcirculation. *Infective endocarditis* - **Infective endocarditis** on a VSD can lead to valve damage, vegetations, emboli, and worsening cardiac function, not improvement of heart failure. - It would typically cause new or worsening symptoms like fever, fatigue, and signs of cardiac decompensation. *Aortic regurgitation* - **Aortic regurgitation** (AR) could occur in rare cases due to prolapse of an aortic valve leaflet into the VSD, which would increase left ventricular volume overload. - This would worsen, rather than improve, the signs and symptoms of **congestive heart failure**. *Closure of VSD spontaneously* - While spontaneous closure of a VSD would definitively improve heart failure symptoms, the question implies a long-standing large VSD where other changes are occurring. - Spontaneous closure is more common in smaller VSDs, and in large VSDs, it would resolve the underlying cause of heart failure, not lead to improvement through a pathological process.

Q: A child presented at 10 weeks with recurrent episode of pneumonia and failure to thrive. X-ray shows cardiomegaly & pulmonary plethora. What is the diagnosis?

VSD. ***VSD*** - **Ventricular septal defect (VSD)** is the most common cause of this presentation in early infancy (symptoms typically appear at **6-10 weeks** of age). - Large VSDs cause significant **left-to-right shunt** leading to pulmonary overcirculation, resulting in **recurrent pneumonia** and **failure to thrive**. - **Cardiomegaly** (due to volume overload of left atrium and ventricle) and **pulmonary plethora** (increased pulmonary vascular markings) on X-ray are classic findings. - The infant may also present with tachypnea, feeding difficulties, and poor weight gain. *TOF* - **Tetralogy of Fallot (TOF)** is a **cyanotic heart defect** with right-to-left shunt, presenting with cyanosis and hypoxic spells, not recurrent pneumonia. - X-ray shows **boot-shaped heart** and **pulmonary oligemia** (decreased pulmonary vascular markings), not pulmonary plethora. - Does not typically cause failure to thrive in the same manner as acyanotic left-to-right shunt lesions. *Patent foramen ovale* - A **patent foramen ovale (PFO)** is a normal variant in infants and typically remains **asymptomatic**. - Does not cause significant hemodynamic shunting in the absence of elevated right atrial pressure. - Does not cause **cardiomegaly**, **pulmonary plethora**, recurrent pneumonia, or failure to thrive. *ASD* - An **atrial septal defect (ASD)** also causes left-to-right shunt with pulmonary plethora, but the shunt develops **gradually** over time. - ASD typically presents **later in childhood or adulthood** with milder symptoms (fatigue, exercise intolerance) due to lower pressure gradient across atria. - **Recurrent pneumonia and failure to thrive at 10 weeks** are uncommon with isolated ASD, as the hemodynamic changes are less pronounced in early infancy compared to VSD. - When symptomatic in infancy, large ASDs present later (around 6 months to 1 year) rather than at 10 weeks.

Q: In Kawasaki disease, desquamation and denudation of skin from fingers and toes occurs in:

2nd and 3rd week. ***2nd and 3rd week*** - Desquamation and denudation of skin, particularly affecting the **fingers and toes**, is a characteristic late-subacute phase finding in **Kawasaki disease**. - This typically occurs during the **subacute stage** of the illness (around days 10-21), as the acute inflammatory symptoms begin to subside. - Periungual desquamation is one of the hallmark clinical features that helps confirm the diagnosis. *After 6 weeks* - By 6 weeks, most of the acute and subacute symptoms of Kawasaki disease would have fully resolved. - This represents the late convalescent phase where desquamation has typically already occurred and resolved. *After 1st week* - While technically desquamation begins after the first week, this option is too vague and non-specific. - The more precise timing is the **2nd and 3rd weeks**, which better characterizes the subacute phase. *3-6 weeks* - While some desquamation may persist into the early part of this period, the **onset and peak** of desquamation occurs earlier, in the **2nd and 3rd weeks**. - This time frame represents primarily the late subacute to convalescent stage, where desquamation is resolving rather than beginning.

Q: All are true regarding tricuspid atresia except –

Split S2. ***Split S2*** - This is the **EXCEPTION** – tricuspid atresia typically presents with a **SINGLE S2**, not a split S2. - The second heart sound (S2) splitting occurs when aortic (A2) and pulmonary (P2) valve closures are audibly separate. - In tricuspid atresia, the **hypoplastic or absent right ventricle** and **reduced pulmonary blood flow** result in a diminished or absent pulmonary component (P2), leading to a single S2 sound. - The lack of normal right ventricular ejection eliminates the typical splitting pattern. *Left axis deviation in ECG* - This is **TRUE** for tricuspid atresia and therefore not the exception. - Tricuspid atresia classically shows **marked left axis deviation** (typically -30° to -90° on ECG). - This occurs because the **left ventricle is dominant and hypertrophied**, as it must handle both systemic and, indirectly, pulmonary circulation. - The right ventricle is hypoplastic or absent, so left ventricular forces dominate the ECG axis. *Pulmonary oligemia in chest X-ray* - This is **TRUE** for tricuspid atresia and therefore not the exception. - **Pulmonary oligemia** (decreased pulmonary vascular markings) is characteristic on chest X-ray. - Results from **reduced pulmonary blood flow** due to the absence of direct right atrial to right ventricular flow. - Blood reaches the lungs only via a VSD or PDA, leading to diminished pulmonary vasculature appearance. *Patent foramen ovale* - This is **TRUE** for tricuspid atresia and therefore not the exception. - An **atrial septal defect (ASD) or patent foramen ovale (PFO)** is **essential for survival**. - Provides the only pathway for systemic venous return to reach the left atrium and subsequently the systemic circulation. - Without this right-to-left atrial shunt, no blood could reach the systemic circulation, resulting in immediate cardiovascular collapse.

Q: Most characteristic feature of TOF is

Cyanotic spells. ***Cyanotic spells*** - **Cyanotic spells**, also known as "tet spells," are acute episodes of profound hypoxemia that are characteristic of Tetralogy of Fallot (TOF), especially in infants. - These spells are caused by increased right-to-left shunting across the **ventricular septal defect** due to infundibular spasm that increases **pulmonary outflow obstruction**, leading to sudden severe cyanosis, dyspnea, and decreased consciousness. *Squatting* - While **squatting** is a common compensatory mechanism used by older children with TOF to improve oxygen saturation, it is a behavioral adaptation rather than a primary physiological feature. - Squatting increases **systemic vascular resistance**, which reduces right-to-left shunting and forces more blood into the pulmonary circulation. *Clubbing of feet* - **Clubbing of fingers and toes** is a common sign of chronic hypoxemia, which can be seen in various cyanotic congenital heart diseases, including TOF. - However, it is a long-term consequence of hypoxemia rather than a characteristic acute or primary feature specific to TOF. *Recurrent chest infection* - Children with TOF may have an increased risk of **recurrent chest infections** due to their underlying compromised cardiovascular status and hypoxemia. - However, recurrent chest infections are not a unique or characteristic feature of TOF, as they can occur in various pediatric conditions that affect respiratory health.

Q: A child after 4 weeks of birth, is acyanotic. Ejection systolic murmur detected on auscultation. Probable diagnosis is:

Coarctation of aorta. ***Coarctation of aorta*** - **Coarctation of the aorta** commonly presents with an **ejection systolic murmur** due to increased flow velocity through the narrowed segment. - Infants are often **acyanotic**, and symptoms like poor feeding or heart failure may develop as the **ductus arteriosus closes**. - The murmur is typically heard at the **left infraclavicular area and back** (interscapular region). *TOF* - **Tetralogy of Fallot** (TOF) is a **cyanotic heart defect**, which contradicts the patient's acyanotic presentation. - It typically presents with a **harsh systolic ejection murmur** at the upper left sternal border and **cyanotic spells**. *VSD* - A **ventricular septal defect** (VSD) typically produces a **holosystolic (pansystolic) murmur** best heard at the lower left sternal border, not an ejection systolic murmur. - While VSD is the most common congenital heart defect, the **murmur type** (holosystolic vs ejection systolic) is the key differentiating feature in this case. *PDA* - A **patent ductus arteriosus** (PDA) leads to a **continuous, machinery-like murmur** due to constant flow between the aorta and pulmonary artery. - It's not typically described as an ejection systolic murmur and can present with signs of **heart failure** or **pulmonary hypertension**.

Q: In the evaluation of congenital heart disease, which of the following findings is considered the LEAST specific diagnostic indicator?

Abnormal ECG findings. ***Abnormal ECG findings*** - While an electrocardiogram (ECG) is an important tool in evaluating congenital heart disease, **abnormal ECG findings** are relatively **non-specific** and can be seen in many conditions. - ECG changes may include axis deviation, chamber hypertrophy patterns, or conduction abnormalities, but these findings alone do not establish the specific diagnosis of congenital heart disease. - Some children with congenital heart disease may have **normal ECG findings**, particularly in mild cases or certain lesions like small atrial septal defects. - ECG serves as a supportive tool but requires correlation with clinical findings and echocardiography for definitive diagnosis. *Presence of a diastolic murmur* - A **diastolic murmur in a child** is highly pathological and almost always indicates significant cardiac pathology. - Diastolic murmurs suggest **aortic regurgitation**, **pulmonary regurgitation**, or **mitral stenosis**, which can be associated with congenital heart defects. - The presence of a diastolic murmur warrants immediate further investigation with echocardiography. *Congestive heart failure* - **Congestive heart failure (CHF)** in infancy or childhood is a critical clinical manifestation often indicating significant congenital heart disease. - Symptoms include tachypnea, failure to thrive, hepatomegaly, and poor feeding in infants. - CHF in children is highly specific for significant cardiac pathology, particularly left-to-right shunts (VSD, PDA) or left-sided obstructive lesions. *Cyanosis as a clinical sign* - **Cyanosis** (bluish discoloration of skin and mucous membranes) indicates arterial oxygen desaturation below 85%. - It is a cardinal sign of **cyanotic congenital heart disease** involving right-to-left shunting (Tetralogy of Fallot, Transposition of Great Arteries) or severe pulmonary obstruction. - Central cyanosis in a neonate is a medical emergency requiring urgent evaluation and management.

Q: Commonest congenital heart disease is:

Ventricular septal defect. ***Ventricular septal defect*** - A **ventricular septal defect (VSD)** is the most frequently observed type of congenital heart disease, accounting for approximately 25-30% of all congenital heart lesions. - It involves an opening in the **interventricular septum**, allowing blood to shunt between the left and right ventricles. *Persistent ductus arteriosus* - While common, **patent ductus arteriosus (PDA)** is not as prevalent as VSDs overall. - PDA is more frequently seen in **premature infants**, but VSDs are the most common in the general population of live births with congenital heart disease. *Atrial septal defect* - **Atrial septal defect (ASD)** is a common congenital heart defect, but its incidence is lower than that of VSDs. - ASDs involve a hole in the **interatrial septum**, leading to shunting of blood between the atria. *Mitral valve prolapse* - **Mitral valve prolapse (MVP)** is a relatively common valvular anomaly but is generally considered a minor congenital heart abnormality or sometimes an acquired condition, not typically classified as the most common "congenital heart disease" in the same category as septal defects. - It involves the leaflets of the **mitral valve bulging into the left atrium** during systole.

Q: The following cardiac defects are characterized by ductus dependent blood flow except –

Truncus arteriosus. ***Truncus arteriosus*** - **Truncus arteriosus** is a congenital heart defect where a single arterial trunk arises from the heart, supplying the systemic, pulmonary, and coronary circulations. - Blood mixing occurs **within the heart itself** at the level of the common truncal valve and ventricular septal defect (VSD), which is always present. - The ductus arteriosus is **not required** for survival because the truncal vessel directly supplies both the systemic and pulmonary circulations. - Therefore, truncus arteriosus is **NOT a ductus-dependent lesion**. *Transposition of great arteries with intact septum* - In **TGA with intact ventricular septum**, the aorta arises from the right ventricle and the pulmonary artery from the left ventricle, creating **parallel circulations**. - The patent ductus arteriosus (PDA) is **critical for mixing** oxygenated and deoxygenated blood, allowing survival until surgical correction. - This is a classic **ductus-dependent lesion** for mixing. *Hypoplastic left heart syndrome* - **HLHS** involves severe underdevelopment of the left ventricle, mitral valve, aortic valve, and ascending aorta. - The **PDA is essential** for providing systemic blood flow, as the right ventricle must supply both pulmonary and systemic circulations via the ductus. - This is a **ductus-dependent systemic circulation** - closure of the PDA is lethal. *Interrupted aortic arch* - **IAA** involves complete discontinuity of the aortic arch, preventing blood flow to the descending aorta. - The **PDA is critical** for perfusing the lower body and abdominal organs. - This is a **ductus-dependent systemic circulation**.

Q: Most common cardiac anomaly in Turner syndrome: CMC (Vellore) 07; CMC (Ludhiana) 13; UPSC 14

Bicuspid aortic valve. ***Bicuspid aortic valve*** - A **bicuspid aortic valve** is the most frequently observed cardiac anomaly in individuals with Turner syndrome, occurring in approximately 15-30% of cases. - This condition involves the **aortic valve** having two leaflets instead of the usual three, which can lead to complications such as **aortic stenosis** or **aortic regurgitation** over time. *Bifurcation of aorta* - **Aortic bifurcation** is a normal anatomical structure where the aorta divides into the common iliac arteries at the level of L4. - This is not a cardiac anomaly, but rather a standard vascular branching pattern. *Coarctation of aorta* - **Coarctation of the aorta** is a narrowing of the aorta, typically near the ductus arteriosus, and is also common in Turner syndrome (occurring in about 10-15%). - Although common, it is **less frequent** than a bicuspid aortic valve. *Aortic stenosis* - **Aortic stenosis** (narrowing of the aortic valve) can be a consequence of a bicuspid aortic valve, but it is not the primary or most common congenital anomaly itself. - The most common **structural defect** that predisposes to aortic stenosis in Turner syndrome is the bicuspid aortic valve.

Question 1

A child with large perimembranous VSD has congestive heart failure. Over time, the child shows clinical improvement in heart failure symptoms despite persistence of the defect. What is the most likely explanation?

Accepted Answer

Vascular changes in pulmonary circulation

Answer

Infective endocarditis

Answer

Aortic regurgitation

Answer

Closure of VSD spontaneously

Question 2

A child presented at 10 weeks with recurrent episode of pneumonia and failure to thrive. X-ray shows cardiomegaly & pulmonary plethora. What is the diagnosis?

Accepted Answer

VSD

Answer

TOF

Answer

Patent foramen ovale

Answer

ASD

Question 3

In Kawasaki disease, desquamation and denudation of skin from fingers and toes occurs in:

Accepted Answer

2nd and 3rd week

Answer

After 6 weeks

Answer

After 1st week

Answer

3-6 weeks

Question 4

All are true regarding tricuspid atresia except –

Accepted Answer

Split S2

Answer

Left axis deviation in ECG.

Answer

Pulmonary oligemia in chest X–ray

Answer

Patent foramen ovale

Question 5

Most characteristic feature of TOF is

Accepted Answer

Cyanotic spells

Answer

Squatting

Answer

Clubbing of feet

Answer

Recurrent chest infection

Question 6

A child after 4 weeks of birth, is acyanotic. Ejection systolic murmur detected on auscultation. Probable diagnosis is:

Accepted Answer

Coarctation of aorta

Answer

TOF

Answer

VSD

Answer

PDA

Question 7

In the evaluation of congenital heart disease, which of the following findings is considered the LEAST specific diagnostic indicator?

Accepted Answer

Abnormal ECG findings

Answer

Presence of a diastolic murmur

Answer

Congestive heart failure

Answer

Cyanosis as a clinical sign

Question 8

Commonest congenital heart disease is:

Accepted Answer

Ventricular septal defect

Answer

Patent ductus arteriosus

Answer

Atrial septal defect

Answer

Mitral valve prolapse

Question 9

The following cardiac defects are characterized by ductus dependent blood flow except –

Accepted Answer

Truncus arteriosus

Answer

Hypoplastic left heart syndrome

Answer

Interrupted aortic arch

Answer

Transposition of great arteries with intact septum

Question 10

Most common cardiac anomaly in Turner syndrome: CMC (Vellore) 07; CMC (Ludhiana) 13; UPSC 14

Accepted Answer

Bicuspid aortic valve

Answer

Bifurcation of aorta

Answer

Coarctation of aorta

Answer

Aortic stenosis

Cardiology — MCQs

Cardiology — MCQs

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