Cardiology — MCQs
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A 34-day-old baby presented with increased respiratory effort along with grunting. The infant is always irritable, feeds very poorly, and has not been able to gain weight. There is a history of frequent recurrent pneumonia requiring hospitalization. On examination, the findings include wide pulse pressure, bounding peripheral pulses, a hyperkinetic apex, a continuous thrill in the 2nd left intercostal space, and a continuous murmur localized to the 2nd left intercostal space and radiating down the left sternal border. Which of the following concomitant findings is most likely to be present in this child?
A newborn with a marked congenital heart defect (CHD) and decreased pulmonary vascularity should be treated with which of the following medications?
Which of the following is FALSE regarding Kawasaki disease?
Which of the following can cause congenital heart block?
All are features of Kawasaki disease, except?
The clinical features associated with coarctation of the aorta in older children are the following, except?
Which of the following is NOT seen in coarctation of the aorta?
What is the least common cause of endocarditis?
What is the treatment for sudden worsening of Tetralogy of Fallot?
Wolff-Parkinson-White disease may be associated with which of the congenital heart defects?
Cardiology Indian Medical PG Practice Questions and MCQs
Question 31: A 34-day-old baby presented with increased respiratory effort along with grunting. The infant is always irritable, feeds very poorly, and has not been able to gain weight. There is a history of frequent recurrent pneumonia requiring hospitalization. On examination, the findings include wide pulse pressure, bounding peripheral pulses, a hyperkinetic apex, a continuous thrill in the 2nd left intercostal space, and a continuous murmur localized to the 2nd left intercostal space and radiating down the left sternal border. Which of the following concomitant findings is most likely to be present in this child?
- A. Nuclear cataract (Correct Answer)
- B. Limb hypoplasias
- C. Optic atrophy
- D. Periventricular calcifications
Explanation: ### Explanation **Diagnosis: Patent Ductus Arteriosus (PDA) secondary to Congenital Rubella Syndrome (CRS)** The clinical presentation of a 34-day-old infant with poor feeding, failure to thrive, and recurrent pneumonia suggests a large left-to-right shunt. The pathognomonic findings of **wide pulse pressure**, **bounding pulses**, and a **continuous (machinery) murmur** at the left infraclavicular area/2nd intercostal space confirm the diagnosis of **Patent Ductus Arteriosus (PDA)**. **1. Why Nuclear Cataract is Correct:** PDA is the most common cardiac defect associated with **Congenital Rubella Syndrome (CRS)**. The classic "Gregg Triad" of CRS includes: * **Cardiac defects:** PDA (most common) or peripheral pulmonary artery stenosis. * **Eye defects:** **Nuclear cataract** ("pearly white" appearance) or glaucoma. * **Sensorineural hearing loss:** The most common overall finding. Given the infant's age and the specific cardiac lesion, a concomitant finding of nuclear cataracts is highly likely as part of this syndrome. **2. Why Incorrect Options are Wrong:** * **Limb hypoplasias:** Associated with **Congenital Varicella Syndrome**, which also presents with cicatricial skin scarring and microcephaly. * **Optic atrophy:** Not a classic feature of CRS; eye involvement in CRS typically involves cataracts, microphthalmia, or "salt and pepper" retinopathy. * **Periventricular calcifications:** A hallmark of **Congenital CMV infection**. In contrast, CRS typically presents with "celery stalking" of long bones or intracranial calcifications that are usually scattered/basal ganglia-located, not periventricular. **Clinical Pearls for NEET-PG:** * **PDA Murmur:** Gibson’s murmur (continuous, peaks at S2). * **CRS Triad:** Cataract, Deafness, PDA. * **Drug of Choice for PDA:** Intravenous Indomethacin or Ibuprofen (NSAIDs) in preterms; surgical/device closure in symptomatic term infants. * **Differential for Continuous Murmur:** Ruptured Sinus of Valsalva (RSV), Aortopulmonary window, Coronary AV fistula.
Question 32: A newborn with a marked congenital heart defect (CHD) and decreased pulmonary vascularity should be treated with which of the following medications?
- A. Digoxin
- B. Indomethacin
- C. Prostaglandin E1 (Correct Answer)
- D. Epinephrine
Explanation: ### Explanation **Correct Answer: C. Prostaglandin E1 (Alprostadil)** **Medical Concept:** The clinical presentation of a newborn with a cyanotic congenital heart defect (CHD) and **decreased pulmonary vascularity** on X-ray indicates a **ductal-dependent pulmonary circulation**. In conditions like Pulmonary Atresia, Tricuspid Atresia, or severe Tetralogy of Fallot, pulmonary blood flow is restricted. The infant relies entirely on the **Ductus Arteriosus** to shunt blood from the aorta to the lungs for oxygenation. As the ductus naturally begins to close within the first hours or days of life, these infants develop profound cyanosis and shock. **Prostaglandin E1 (PGE1)** is life-saving because it maintains the patency of the ductus arteriosus, ensuring adequate pulmonary perfusion until surgical intervention (like a Blalock-Taussig shunt) can be performed. **Why Incorrect Options are Wrong:** * **A. Digoxin:** This is an inotrope used for heart failure or certain arrhythmias (SVT). It does not address the anatomical obstruction to pulmonary blood flow. * **B. Indomethacin:** This is a prostaglandin synthesis inhibitor used to **close** a Patent Ductus Arteriosus (PDA) in preterm infants. In this scenario, closing the ductus would be fatal. * **D. Epinephrine:** While used in resuscitation for cardiac arrest or severe shock, it does not solve the underlying problem of restricted pulmonary blood flow in a ductal-dependent lesion. **High-Yield Clinical Pearls for NEET-PG:** 1. **Ductal-dependent Systemic Circulation:** Conditions like Hypoplastic Left Heart Syndrome or Coarctation of the Aorta also require PGE1 to maintain systemic output. 2. **Side Effect of PGE1:** The most common high-yield side effect to watch for is **Apnea**; always be prepared for endotracheal intubation. 3. **X-ray Finding:** "Decreased pulmonary vascularity" (Oligemic lung fields) is a classic sign of right-to-left shunts with pulmonary obstruction.
Question 33: Which of the following is FALSE regarding Kawasaki disease?
- A. Strawberry tongue
- B. Periungual desquamation
- C. Self-limiting febrile illness
- D. Unilateral, suppurative cervical lymphadenopathy (Correct Answer)
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 ≥5 days along with specific diagnostic criteria. **Why Option D is False:** While **unilateral cervical lymphadenopathy** (usually >1.5 cm) is a classic diagnostic criterion for KD, it is characteristically **non-suppurative**. If a lymph node is fluctuant or draining pus (suppurative), it points toward a bacterial etiology (like *Staphylococcus aureus* lymphadenitis) rather than Kawasaki disease. **Analysis of Other Options:** * **Option A (Strawberry tongue):** This is a classic finding of oral mucosal involvement in KD, caused by the sloughing of filiform papillae and hypertrophy of fungiform papillae. * **Option B (Periungual desquamation):** This is a hallmark of the **subacute phase** (occurring 2–3 weeks after fever onset). Skin peeling begins under the fingernails and toenails. * **Option C (Self-limiting febrile illness):** KD is indeed self-limiting; the fever and acute inflammation usually resolve even without treatment. However, treatment (IVIG) is mandatory to prevent the serious complication of coronary artery aneurysms. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Complication:** Coronary artery aneurysms (occurs in 20–25% of untreated cases). * **Treatment of Choice:** High-dose **IVIG** (2g/kg) plus **Aspirin**. (Note: This is one of the few pediatric conditions where Aspirin is indicated despite the risk of Reye syndrome). * **Cardiac Screening:** Echocardiography should be performed at diagnosis, at 2 weeks, and at 6–8 weeks. * **Incomplete Kawasaki:** Suspect in infants with prolonged fever and fewer than 4 criteria; check ESR/CRP and Echo.
Question 34: Which of the following can cause congenital heart block?
- A. Maternal Systemic Lupus Erythematosus (SLE) (Correct Answer)
- B. Down's syndrome
- C. Edward's syndrome
- D. Phenylketonuria
Explanation: **Explanation:** **Correct Answer: A. Maternal Systemic Lupus Erythematosus (SLE)** Congenital Heart Block (CHB) is most commonly associated with maternal autoimmune diseases, specifically **SLE** and **Sjögren’s syndrome**. The underlying mechanism involves the transplacental passage of maternal IgG autoantibodies, specifically **anti-Ro (SS-A)** and **anti-La (SS-B)**. These antibodies cross the placenta and cause inflammatory damage (myocarditis) and subsequent fibrosis of the fetal AV node and conduction system. This damage is typically irreversible and occurs between 18 and 24 weeks of gestation. **Analysis of Incorrect Options:** * **B. Down’s Syndrome (Trisomy 21):** Most commonly associated with **Atrioventricular Septal Defects (AVSD)** or Endocardial Cushion Defects, followed by VSD and ASD. It does not typically cause heart block. * **C. Edward’s Syndrome (Trisomy 18):** Frequently associated with **Ventricular Septal Defects (VSD)** and Polyvalvular heart disease. * **D. Phenylketonuria (PKU):** Maternal PKU (untreated) is associated with an increased risk of microcephaly, intellectual disability, and cardiac defects like **Tetralogy of Fallot (TOF)** and VSD, but not isolated heart block. **High-Yield Clinical Pearls for NEET-PG:** 1. **Neonatal Lupus:** Presents with a characteristic "raccoon-eye" or periorbital rash and CHB. While the rash is transient (disappears as maternal antibodies wane), the **heart block is permanent**. 2. **Treatment:** If detected in utero, maternal steroids (Dexamethasone) may be used. Postnatally, most symptomatic infants require a **permanent pacemaker**. 3. **Bradycardia:** Congenital heart block is a classic cause of persistent fetal or neonatal bradycardia.
Question 35: All are features of Kawasaki disease, except?
- A. Peak incidence at age > 5 years (Correct Answer)
- B. Aneurysm of coronary artery
- C. Enlarged lymph nodes
- D. Fever
Explanation: **Explanation:** Kawasaki Disease (KD) is an acute, self-limiting systemic medium-vessel vasculitis. It is the leading cause of acquired heart disease in children in developed nations. **Why Option A is the correct answer (The "Except"):** The peak incidence of Kawasaki Disease is in children **younger than 5 years** (specifically between 6 months and 2 years of age). It is rare in infants under 3 months or children older than 8 years. Therefore, "Peak incidence at age > 5 years" is factually incorrect. **Why other options are incorrect (Features of KD):** * **Option B (Coronary Artery Aneurysm):** This is the most serious complication, occurring in 20–25% of untreated cases. It typically develops in the subacute phase. * **Option C (Enlarged Lymph Nodes):** Cervical lymphadenopathy (usually >1.5 cm and unilateral) is one of the five classic diagnostic criteria. * **Option D (Fever):** High-grade, spiking fever lasting for at least 5 days is the mandatory hallmark for diagnosis. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnostic Criteria (CRASH and Burn):** **C**onjunctivitis (bilateral, non-purulent), **R**ash (polymorphous), **A**denopathy (cervical), **S**trawberry tongue (and oral mucosal changes), **H**ands/feet (edema/erythema/desquamation), and **Burn** (Fever ≥ 5 days). * **Treatment:** High-dose **IVIG** (2g/kg) and **Aspirin**. IVIG is most effective if given within the first 10 days to prevent coronary aneurysms. * **Incomplete Kawasaki:** Common in infants; requires high clinical suspicion as they are at high risk for aneurysms despite not meeting all criteria. * **Echo:** Should be performed at diagnosis, at 2 weeks, and 6–8 weeks.
Question 36: The clinical features associated with coarctation of the aorta in older children are the following, except?
- A. Upper body hypertension
- B. Prominent pulsation in the neck
- C. Fatigability and tiredness in the legs
- D. Absence of flow murmurs over the scapular region (Correct Answer)
Explanation: **Explanation:** Coarctation of the aorta (CoA) is a localized narrowing of the aortic lumen, typically occurring near the insertion of the ductus arteriosus. In older children, the clinical presentation is dominated by the development of **collateral circulation** and upper-body hypertension. **Why Option D is the Correct Answer:** In older children with significant coarctation, the body develops extensive collateral vessels (intercostal, internal mammary, and scapular arteries) to bypass the obstruction. These dilated, tortuous vessels produce **continuous or systolic flow murmurs** and bruits that are characteristically heard over the **scapular region** and back. Therefore, the "absence" of these murmurs is incorrect; their presence is a hallmark sign. **Analysis of Incorrect Options:** * **A. Upper body hypertension:** This is the classic finding. Obstruction leads to high pressure proximal to the coarctation, resulting in hypertension in the arms. * **B. Prominent pulsation in the neck:** High stroke volume and pressure in the carotid arteries often lead to visible suprasternal or carotid pulsations. * **C. Fatigability and tiredness in the legs:** Due to the narrowing, there is reduced distal perfusion (lower body ischemia), leading to leg pain or "claudication" during exercise. **NEET-PG High-Yield Pearls:** * **Physical Exam:** Look for the "Radio-femoral delay" and a significant BP pressure gradient between the upper and lower limbs. * **X-ray Findings:** "Rib notching" (due to dilated intercostal arteries eroding the lower borders of the 3rd–8th ribs) and the **"3 sign"** on the barium swallow/chest X-ray. * **Association:** Strongly associated with **Turner Syndrome** (15-20% of cases) and **Bicuspid Aortic Valve** (most common cardiac anomaly). * **Gold Standard Diagnosis:** CT Angiography or MRI; however, Echocardiography is the initial screening tool.
Question 37: Which of the following is NOT seen in coarctation of the aorta?
- A. High blood pressure in the right arm compared to the left arm
- B. Persistent hypertension despite complete surgical repair
- C. A systolic murmur heard best over the anterior chest and back, and a high-pitched diastolic murmur along the left sternal border
- D. Inability to augment cardiac output with exercise (Correct Answer)
Explanation: **Explanation:** **Coarctation of the Aorta (CoA)** is a localized narrowing of the aorta, typically near the insertion of the ductus arteriosus. **Why Option D is the correct answer:** Patients with CoA **can** typically augment their cardiac output during exercise. While they may experience an exaggerated hypertensive response in the upper extremities during physical activity, the left ventricle is usually compensated (hypertrophied) enough to increase stroke volume and heart rate, thereby increasing total cardiac output. "Inability to augment cardiac output" is more characteristic of severe congestive heart failure or fixed obstructive lesions like critical aortic stenosis. **Analysis of Incorrect Options:** * **Option A:** If the coarctation is **pre-ductal** or involves the origin of the left subclavian artery, the blood pressure in the right arm will be significantly higher than in the left arm. * **Option B:** Persistent hypertension is a well-known long-term complication even after successful surgical repair. This is attributed to permanent changes in baroreceptor sensitivity and renin-angiotensin system activation. * **Option C:** The systolic murmur is produced by flow across the narrowing (heard at the back/interscapular area). The high-pitched diastolic murmur is often due to an associated **Bicuspid Aortic Valve (BAV)**, which occurs in up to 50-85% of CoA cases, leading to aortic regurgitation. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Sign:** Radio-femoral delay and upper limb hypertension. * **X-ray Findings:** "Figure of 3" sign on chest X-ray and **rib notching** (due to collateral flow through intercostal arteries; usually involves 3rd to 8th ribs). * **Association:** Strongly associated with **Turner Syndrome** (45, XO). * **Gold Standard Investigation:** CT Angiography or Cardiac MRI.
Question 38: What is the least common cause of endocarditis?
- A. Atrial Septal Defect (ASD) (Correct Answer)
- B. Patent Ductus Arteriosus (PDA)
- C. Tetralogy of Fallot (TOF)
- D. Ventricular Septal Defect (VSD)
Explanation: **Explanation:** In Infective Endocarditis (IE), the primary pathophysiology involves **high-velocity turbulent blood flow** that causes endothelial damage. This damage leads to the deposition of fibrin and platelets (Non-Bacterial Thrombotic Endocarditis), which then serves as a nidus for bacterial colonization. **Why ASD is the correct answer:** Atrial Septal Defects (specifically Ostium Secundum) are associated with a **low-pressure gradient** between the left and right atria. Because the pressure difference is minimal, the blood flow is non-turbulent and of low velocity. Consequently, there is insufficient endothelial trauma to predispose the heart to bacterial vegetation. Therefore, isolated ASD is the least common cause and generally does not require IE prophylaxis. **Analysis of Incorrect Options:** * **VSD (Ventricular Septal Defect):** This is a high-pressure shunt. The high-velocity jet from the left ventricle strikes the right ventricular endocardium, causing significant turbulence and making it a common site for IE. * **PDA (Patent Ductus Arteriosus):** The high-pressure gradient between the aorta and the pulmonary artery creates significant turbulence at the pulmonary end of the ductus, carrying a high risk for endarteritis. * **TOF (Tetralogy of Fallot):** Cyanotic heart diseases like TOF involve high-velocity flow across the VSD and right ventricular outflow tract obstruction, making them high-risk categories for IE. **NEET-PG High-Yield Pearls:** 1. **Most common underlying lesion for IE in children:** Ventricular Septal Defect (VSD). 2. **Most common underlying lesion for IE in adults:** Mitral Valve Prolapse (MVP). 3. **Highest risk lesions:** Prosthetic valves, prior history of IE, and cyanotic heart disease (unrepaired). 4. **Note:** While ASD is low risk, **Primum ASD** or **Sinus Venosus ASD** may have a slightly higher risk if associated with valvular regurgitation, but Ostium Secundum remains the least common overall.
Question 39: What is the treatment for sudden worsening of Tetralogy of Fallot?
- A. PGE1 infusion
- B. Oxygen therapy
- C. Propranolol
- D. All of the above (Correct Answer)
Explanation: **Explanation:** Sudden worsening of Tetralogy of Fallot (TOF) is clinically known as a **Hypercyanotic Spell** or **"Tet Spell."** This occurs due to an acute increase in right-to-left shunting, usually triggered by a decrease in systemic vascular resistance (SVR) or an increase in pulmonary vascular resistance (PVR) caused by infundibular spasm. **Why "All of the Above" is Correct:** The management of a Tet spell aims to increase SVR, decrease PVR, and relax the infundibular spasm. * **Oxygen therapy (B):** Acts as a potent pulmonary vasodilator, reducing PVR and improving oxygenation. * **Propranolol (C):** A beta-blocker used to relax the infundibular muscle spasm and slow the heart rate, allowing better ventricular filling. * **PGE1 infusion (D):** In neonates with severe TOF or pulmonary atresia, PGE1 is life-saving to maintain ductal patency (PDA), ensuring pulmonary blood flow. **Clinical Pearls for NEET-PG:** 1. **First-line physical maneuver:** Knee-chest position (increases SVR by kinking femoral arteries). 2. **Drug of choice for acute spell:** Morphine (sedates the child and reduces tachypnea). 3. **Vasopressor of choice:** Phenylephrine (increases SVR without increasing heart rate). 4. **Maintenance therapy:** Oral Propranolol is used to prevent future spells until definitive surgery. 5. **Definitive Treatment:** Total surgical correction (VSD closure and relief of RVOT obstruction). **Summary:** Management is a multi-modal approach involving positioning, oxygenation, sedation, and pharmacological intervention to restore hemodynamics.
Question 40: Wolff-Parkinson-White disease may be associated with which of the congenital heart defects?
- A. Tetralogy of Fallot
- B. Patent Ductus Arteriosus (PDA)
- C. Ebstein's anomaly (Correct Answer)
- D. All of the above
Explanation: **Explanation:** **Ebstein’s Anomaly** is the congenital heart defect most classically associated with **Wolff-Parkinson-White (WPW) syndrome**. In Ebstein’s anomaly, there is a failure of delamination of the tricuspid valve leaflets, leading to their downward displacement into the right ventricle ("atrialization" of the RV). This structural abnormality is frequently accompanied by **accessory pathways** (Bundle of Kent), particularly located around the malformed tricuspid annulus on the right side of the heart. Approximately 10–20% of patients with Ebstein’s anomaly have WPW syndrome, often involving multiple accessory pathways. **Analysis of Incorrect Options:** * **Tetralogy of Fallot (TOF):** While TOF is associated with right bundle branch block (RBBB) and ventricular arrhythmias post-repair, it does not have a specific developmental association with accessory atrioventricular pathways. * **Patent Ductus Arteriosus (PDA):** PDA is an extracardiac shunt. It leads to volume overload of the left heart but is not associated with the conduction system abnormalities seen in WPW. **High-Yield Clinical Pearls for NEET-PG:** * **WPW in Ebstein’s:** Usually involves **Right-sided accessory pathways**. * **ECG Triad of WPW:** Short PR interval (<0.12s), Delta wave (slurred upstroke of QRS), and prolonged QRS complex. * **Drug of Choice:** For acute orthodromic SVT in WPW, Adenosine is used. However, for permanent destruction of the pathway, **Radiofrequency Ablation** is the definitive treatment. * **Avoid:** "ABCD" drugs (Adenosine, Beta-blockers, Calcium channel blockers, Digoxin) in patients with WPW and Atrial Fibrillation, as they can paradoxically increase conduction through the accessory pathway, leading to Ventricular Fibrillation.
Practice by Chapter
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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