Cardiology Practice Questions

Q: Which of the following is NOT a sign of congestive cardiac failure in infants?

Large volume pulse. In infants, congestive cardiac failure (CCF) is primarily a clinical diagnosis characterized by sympathetic overactivity and systemic/pulmonary venous congestion. ### **Why "Large Volume Pulse" is the Correct Answer** In CCF, the heart is unable to maintain an adequate cardiac output. This leads to a **low stroke volume**, which clinically manifests as a **small volume (thready) pulse** and tachycardia. A **large volume (bounding) pulse** is characteristic of conditions with a wide pulse pressure, such as Patent Ductus Arteriosus (PDA), Aortic Regurgitation, or high-output states—not heart failure itself. ### **Explanation of Other Options** * **Gallop Rhythm (S3):** This is a hallmark sign of ventricular dysfunction in infants. The S3 occurs during the rapid ventricular filling phase and signifies a dilated, non-compliant ventricle. * **Lack of Weight Gain:** This is often the earliest sign of CCF in infants (Failure to Thrive). It occurs due to a combination of hypermetabolism (increased work of breathing/heart) and poor caloric intake (suck-rest-suck cycle/interrupted feeding). * **Peripheral Cyanosis:** In CCF, low cardiac output leads to increased oxygen extraction by peripheral tissues and poor cutaneous perfusion, resulting in cold extremities and peripheral cyanosis (acrocyanosis). ### **High-Yield Clinical Pearls for NEET-PG** * **Most common cause of CCF in the first week of life:** Hypoplastic Left Heart Syndrome. * **Most common cause of CCF in the first month:** Coarctation of Aorta or large PDA. * **Clinical Triad of CCF in Infants:** Tachycardia, Tachypnea, and Hepatomegaly (tender). * **Note on Edema:** Unlike adults, peripheral pedal edema is rare in infants; instead, they present with **periorbital edema** or excessive weight gain due to fluid retention before it becomes clinically visible.

Q: Which of the following is NOT a cause of Long QT syndrome in children?

Holt-Oram Syndrome. **Explanation:** The correct answer is **Holt-Oram Syndrome** because it is a "Heart-Hand" syndrome characterized by upper limb radial ray defects and structural cardiac defects (most commonly **Secundum ASD**), but it does **not** involve the cardiac conduction system's repolarization phase (QT interval). **Why the other options are causes of Long QT Syndrome (LQTS):** * **Romano-Ward Syndrome (Option A):** This is the most common **autosomal dominant** form of congenital LQTS. It involves only cardiac manifestations (prolonged QT interval and risk of Torsades de Pointes) without associated deafness. * **Jervell and Lange-Nielsen Syndrome (Option B):** This is a rare **autosomal recessive** form of congenital LQTS. It is characterized by a very long QT interval and is uniquely associated with **sensorineural deafness**. * **Macrolide Antibiotics (Option C):** These are a classic cause of **acquired LQTS**. Drugs like Erythromycin and Azithromycin block the delayed rectifier potassium channels (IKr), delaying repolarization. **High-Yield NEET-PG Pearls:** 1. **Holt-Oram Syndrome:** Look for "triphalangeal thumbs" or absent radii + ASD/VSD in the clinical stem. It is associated with the **TBX5 gene** mutation. 2. **LQTS Management:** The first-line treatment for congenital LQTS is **Beta-blockers** (Propranolol or Nadolol). 3. **Torsades de Pointes:** This is the life-threatening polymorphic ventricular tachycardia seen in LQTS; the acute treatment of choice is **Magnesium Sulfate**. 4. **Electrolyte triggers:** Hypokalemia, hypomagnesemia, and hypocalcemia can all trigger or worsen QT prolongation.

Q: All are true in Kawasaki disease except?

Exudative conjunctivitis. **Explanation:** Kawasaki Disease (KD) is an acute, self-limiting systemic medium-vessel vasculitis. Diagnosis is primarily clinical, based on the **CRASH and Burn** mnemonic (Fever for ≥5 days + 4 out of 5 clinical criteria). **Why Option A is the correct answer:** The conjunctivitis in Kawasaki disease is classically **bilateral, non-exudative (dry), and bulbar**, often with limbic sparing. The presence of pus or exudate should prompt a clinician to look for alternative diagnoses, such as Adenovirus or Stevens-Johnson Syndrome. **Analysis of Incorrect Options:** * **B. 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). * **C. Strawberry tongue:** This is a hallmark of the "Oral mucosal changes" criterion, which also includes cracked, erythematous lips and oropharyngeal injection. * **D. Thrombocytosis:** While not a diagnostic criterion, a high platelet count (often >4.5 lakh/µL) is a characteristic laboratory finding that typically appears in the **second week** (subacute phase) of the illness. **NEET-PG High-Yield Pearls:** * **Most common cause** of acquired heart disease in children in developed nations. * **Cardiac Complication:** Coronary artery aneurysms (most common in the subacute phase). * **Treatment:** High-dose IVIG (2g/kg) + Aspirin. (Note: This is one of the few pediatric conditions where Aspirin is used despite the risk of Reye syndrome). * **Incomplete Kawasaki:** Suspect in infants with prolonged fever; requires Echo and inflammatory markers (ESR/CRP) for diagnosis.

Q: What is the most common manifestation of rheumatic fever?

Arthritis. Acute Rheumatic Fever (ARF) is a multisystem autoimmune response following a Group A Streptococcal (GAS) pharyngeal infection. Diagnosis is based on the **Revised Jones Criteria**, which categorizes clinical features into Major and Minor manifestations. ### Why Arthritis is the Correct Answer **Arthritis** is the **most common** major manifestation of ARF, occurring in approximately **75% of patients**. It typically presents as a "migratory polyarthritis," involving large joints (knees, ankles, elbows, wrists) in succession. A hallmark of this arthritis is its dramatic response to salicylates (aspirin) within 24–48 hours. ### Analysis of Incorrect Options * **B. Carditis:** This is the **most serious** manifestation and the only one that leads to permanent disability (chronic rheumatic heart disease). It occurs in about 50–60% of cases. * **C. Chorea (Sydenham’s):** This occurs in about 10–15% of patients. It is characterized by purposeless, involuntary movements and emotional lability. It has a long latent period (months) after the initial infection. * **D. Nodules (Subcutaneous):** These are rare (<1–5%) and are almost always associated with severe carditis. They are firm, painless, and located over bony prominences. ### NEET-PG High-Yield Pearls * **Most common manifestation:** Migratory Polyarthritis. * **Most common valve involved:** Mitral Valve (Mitral Regurgitation in acute phase; Mitral Stenosis in chronic phase). * **Most specific finding:** Aschoff bodies (pathognomonic on histology). * **Least common major criteria:** Subcutaneous nodules. * **Erythema Marginatum:** The characteristic rash of ARF (evanescent, non-pruritic, pink rings).

Q: Which of the following is NOT included in the revised Jones criteria?

History of scarlet fever. The **Revised Jones Criteria (2015)** are used to diagnose Acute Rheumatic Fever (ARF), a non-suppurative sequela of Group A Streptococcal (GAS) pharyngitis. To make a diagnosis, one must demonstrate **evidence of a preceding GAS infection** plus specific Major and Minor clinical/laboratory criteria. **Why "History of Scarlet Fever" is the correct answer:** While Scarlet Fever is caused by Group A Streptococcus, a mere "history" of the disease is subjective and does not fulfill the objective laboratory requirements for current evidence of GAS infection. The 2015 revision emphasizes objective testing (culture, antigen, or titers) rather than clinical history alone. **Analysis of Incorrect Options (Required Evidence of GAS Infection):** * **Option A & B:** A positive **Throat Culture** or a **Rapid Antigen Detection Test (RADT)** are primary methods to confirm recent streptococcal presence in the pharynx. * **Option C:** **Elevated or rising Antistreptolysin O (ASO) or Anti-DNase B titers** are the most reliable indicators of a recent "preceding" infection, especially since the pharyngeal infection has often resolved by the time ARF symptoms appear. **High Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** 2 Major OR 1 Major + 2 Minor criteria (plus evidence of GAS infection). * **Major Criteria (JONES):** **J**oints (Migratory Polyarthritis), **O** (Carditis), **N**odules (Subcutaneous), **E**rythema Marginatum, **S**ydenham Chorea. * **2015 Update:** The criteria now differentiate between **Low-risk** and **Moderate/High-risk populations**. For example, Monoarthritis or Polyarthralgia are considered Major criteria in High-risk populations. * **Exceptions:** Sydenham chorea or indolent carditis can diagnose ARF without overt evidence of preceding GAS infection.

Q: How is congestive cardiac failure diagnosed in an infant?

Hepatomegaly. In infants, the clinical presentation of Congestive Cardiac Failure (CCF) differs significantly from adults due to physiological and anatomical differences. **Why Hepatomegaly is the Correct Answer:** In infants, the liver is highly distensible and serves as the primary reservoir for venous congestion. **Hepatomegaly** (specifically a firm liver edge >2 cm below the costal margin) is the **earliest and most reliable clinical sign** of systemic venous congestion in pediatric heart failure. It is often used to monitor the response to treatment (e.g., the liver size decreases as the infant improves). **Why the Other Options are Incorrect:** * **Basal Crepitations (A):** While a hallmark of left-sided heart failure in adults, rales/crepitations are often **absent or late findings** in infants. Instead, infants present with tachypnea, retractions, and grunting. * **Elevated Jugular Venous Pressure (B):** JVP is **extremely difficult to assess** in infants because their necks are short and they have an abundance of subcutaneous fat, making the jugular veins non-visible. * **Pedal Edema (C):** Dependent edema is rare in infants. Instead of pedal edema, fluid retention in infants typically manifests as **periorbital edema** or excessive weight gain. **High-Yield Clinical Pearls for NEET-PG:** 1. **Earliest Sign of CCF in Infants:** Tachycardia (at rest). 2. **Most Common Cause of CCF in first week of life:** Hypoplastic Left Heart Syndrome (HLHS). 3. **Most Common Cause of CCF in first month of life:** Coarctation of Aorta and Large VSD. 4. **Feeding History:** "Feeding difficulties" (taking too long to feed, forehead sweating during feeds, and interrupted feeds) are classic early symptoms of pediatric CCF.

Q: Which congenital heart defect (CHD) will lead to a left-to-right shunt, generally with cyanosis?

Total anomalous pulmonary venous connection. **Explanation:** The core concept here is the distinction between **simple shunts** (acyanotic) and **mixing lesions** (cyanotic). **Why Option C is Correct:** In **Total Anomalous Pulmonary Venous Connection (TAPVC)**, all four pulmonary veins drain into the right atrium (or systemic veins) instead of the left atrium. This creates a **left-to-right shunt** because oxygenated blood returns to the right side of the heart. However, because the entire systemic and pulmonary venous return mixes in the right atrium, the blood entering the left side (via an obligatory ASD/PFO) is a mixture of oxygenated and deoxygenated blood. This "obligatory mixing" results in **cyanosis** despite the massive left-to-right shunt. **Analysis of Incorrect Options:** * **A. ALCAPA:** This results in a left-to-right shunt (from the RCA to the LCA and then into the pulmonary artery), but it typically presents with myocardial ischemia/infarction and heart failure in infancy, not primary cyanosis. * **B. PDA & D. VSD:** These are classic left-to-right shunts. They are **acyanotic** because oxygenated blood from the left side moves to the right side. Cyanosis only occurs in these conditions if pulmonary hypertension develops, leading to a shunt reversal (**Eisenmenger Syndrome**). **High-Yield Clinical Pearls for NEET-PG:** * **TAPVC Radiology:** The supracardiac type (Type I) shows the classic **"Figure of 8"** or **"Snowman"** appearance on X-ray. * **The "5 Ts" of Cyanotic CHD:** Tetralogy of Fallot, Transposition of Great Arteries, Tricuspid Atresia, **TAPVC**, and Truncus Arteriosus. * **Mixing Lesions:** TAPVC and Truncus Arteriosus are unique because they feature both a left-to-right shunt (increased pulmonary blood flow) and clinical cyanosis.

Q: What is the most appropriate management for maintaining patency of the ductus arteriosus in a neonate?

Prostaglandin E1. **Explanation:** In neonates with ductal-dependent congenital heart diseases (such as Transposition of the Great Arteries, Hypoplastic Left Heart Syndrome, or Pulmonary Atresia), maintaining the patency of the **Ductus Arteriosus (DA)** is life-saving to ensure systemic or pulmonary blood flow. **Correct Option: A. Prostaglandin E1 (Alprostadil)** Prostaglandin E1 (PGE1) is a potent vasodilator that acts directly on the smooth muscle of the ductus arteriosus to prevent its physiological closure. It is the gold-standard treatment for maintaining ductal patency until definitive surgical intervention can be performed. **Why Incorrect Options are Wrong:** * **B. Oxygen:** Oxygen is a potent **constrictor** of the ductus arteriosus. High concentrations of oxygen after birth trigger the closure of the DA by decreasing pulmonary vascular resistance and inhibiting local prostaglandin production. * **C. Nitric Oxide:** This is a selective pulmonary vasodilator used to treat Persistent Pulmonary Hypertension of the Newborn (PPHN). It does not have a primary role in maintaining ductal patency. * **D. Indomethacin:** This is a non-selective COX inhibitor that inhibits prostaglandin synthesis. It is used to **close** a Patent Ductus Arteriosus (PDA) in premature infants, the exact opposite of the goal in this question. **High-Yield Clinical Pearls for NEET-PG:** * **Side Effect of PGE1:** The most critical side effect to monitor during PGE1 infusion is **apnea**; always be prepared for endotracheal intubation. * **Closure of DA:** Functional closure occurs within 10–15 hours of birth; anatomical closure occurs by 2–3 weeks (forming the *ligamentum arteriosum*). * **Drug of Choice for PDA Closure:** IV Indomethacin or Ibuprofen (Ibuprofen is often preferred due to fewer renal side effects). Paracetamol is a newer alternative.

Q: Which of the following is NOT included in the modified Jones criteria?

Prolonged QRS interval. The **Modified Jones Criteria** are used for the diagnosis of **Acute Rheumatic Fever (ARF)**, a non-suppurative sequela of Group A Streptococcus infection [1]. ### **Explanation of the Correct Answer** **Option A (Prolonged QRS interval)** is the correct answer because it is **not** part of the Jones criteria. In ARF, the characteristic ECG finding included in the Minor Criteria is a **prolonged PR interval** (first-degree AV block), not a prolonged QRS. A prolonged QRS usually indicates bundle branch blocks or ventricular conduction delays, which are not specific to ARF. ### **Analysis of Incorrect Options** The Jones criteria are divided into Major and Minor categories. Options B, C, and D are all **Major Criteria**: * **Carditis (B):** Clinical or subclinical (detected by Echo) involvement of the endocardium, myocardium, or pericardium (pancarditis) [1]. * **Chorea (C):** Also known as Sydenham’s chorea or "St. Vitus' dance," characterized by rapid, purposeless movements [1]. * **Erythema Marginatum (D):** A classic evanescent, non-pruritic, pink ring-like rash with central clearing. ### **NEET-PG High-Yield Pearls** * **Mnemonic for Major Criteria (JONES):** **J**oints (Migratory Polyarthritis), **O** (Heart - Carditis), **N**odules (Subcutaneous), **E**rythema marginatum, **S**ydenham’s chorea. * **Minor Criteria:** Fever, Arthralgia, Elevated ESR/CRP, and **Prolonged PR interval**. * **Diagnosis Requirement:** 2 Major OR 1 Major + 2 Minor criteria, plus evidence of preceding Streptococcal infection (ASO titer/Throat culture) [1]. * **Exception:** Chorea or indolent carditis can be diagnostic of ARF on their own without meeting other criteria [1]. * **Most common valve affected:** Mitral valve (Mitral Regurgitation in acute phase; Mitral Stenosis in chronic phase).

Question 1

Which of the following is NOT a sign of congestive cardiac failure in infants?

Accepted Answer

Large volume pulse

Answer

Gallop rhythm (S3)

Answer

Lack of weight gain

Answer

Peripheral cyanosis

Question 2

Which of the following is NOT a cause of Long QT syndrome in children?

Accepted Answer

Holt-Oram Syndrome

Answer

Romano Ward syndrome

Answer

Jervell and Lange-Nielsen Syndrome

Answer

Macrolide antibiotics

Question 3

All are true in Kawasaki disease except?

Accepted Answer

Exudative conjunctivitis

Answer

Pedal edema

Answer

Strawberry tongue

Answer

Thrombocytosis

Question 4

What is the most common manifestation of rheumatic fever?

Accepted Answer

Arthritis

Answer

Carditis

Answer

Chorea

Answer

Nodules

Question 5

Which of the following is NOT included in the revised Jones criteria?

Accepted Answer

History of scarlet fever

Answer

Throat culture positive for Group A Streptococcus

Answer

Rapid antigen detection test positive for Group A Streptococcus

Answer

Anti-DNase B titer elevated

Question 6

How is congestive cardiac failure diagnosed in an infant?

Accepted Answer

Hepatomegaly

Answer

Basal crepitations

Answer

Elevated jugular venous pressure

Answer

Pedal edema

Question 7

Which congenital heart defect (CHD) will lead to a left-to-right shunt, generally with cyanosis?

Accepted Answer

Total anomalous pulmonary venous connection

Answer

Anomalous origin of the left coronary artery from the pulmonary trunk

Answer

Patent ductus arteriosus without pulmonary hypertension

Answer

Ventricular septal defect

Question 8

What is the most appropriate management for maintaining patency of the ductus arteriosus in a neonate?

Accepted Answer

Prostaglandin E1

Answer

Oxygen

Answer

Nitric oxide

Answer

Indomethacin

Question 9

Physical examination of a neonate is remarkable for a holosystolic murmur. There is no cyanosis. Echocardiography demonstrates an ostium primum defect in the lower part of the interatrial septum that is accompanied by malformations of the adjacent atrioventricular valves. These lesions are most likely associated with which of the following disorders?

Accepted Answer

Down syndrome

Answer

Cystic fibrosis

Answer

Gaucher disease

Answer

Marfan syndrome

Question 10

Which of the following is NOT included in the modified Jones criteria?

Accepted Answer

Prolonged QRS interval

Answer

Carditis

Answer

Chorea

Answer

Erythema marginatum

Cardiology — MCQs

Cardiology — MCQs

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