Cardiology — MCQs

A 1-year-old child presents with mental retardation, seizures, and facial angiofibromas. The child also experiences repeated episodes of syncope. An echocardiogram reveals a mass in the left ventricle causing intermittent obstruction. Pathologic examination of the resected mass demonstrates a cardiac rhabdomyoma. Which of the following lesions would this patient most likely also have?

Q85Easy

What is the most common benign tumor of the heart in children?

Q86Easy

All are true in Kawasaki disease except?

Q87Easy

What is the most common manifestation of rheumatic fever?

Q88Easy

How is congestive cardiac failure diagnosed in an infant?

Q89Medium

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

Q90Easy

Modified Jones's criteria includes all the following as major criteria except?

Cardiology Indian Medical PG Practice Questions and MCQs

Question 81: Which congenital heart disease is associated with the defect shown in the diagram below?

A. Tricuspid atresia
B. Hypoplastic left ventricle
C. Aortic stenosis
D. Endocardial cushion defect (Correct Answer)

Explanation: ***Endocardial cushion defect*** - Characterized by **primum atrial septal defect**, **inlet ventricular septal defect**, and **common atrioventricular valve**, creating the classic "gooseneck" appearance on chest X-ray. - Strongly associated with **Down syndrome** (trisomy 21) and presents with early **congestive heart failure** and **failure to thrive**. *Tricuspid atresia* - Involves **absence or imperforation of the tricuspid valve**, causing blood to bypass the right ventricle entirely. - Results in **cyanosis** from birth and requires blood flow through **atrial septal defect** and **patent ductus arteriosus** for survival. *Hypoplastic left ventricle* - Features **underdevelopment of the left ventricle**, **mitral valve**, and **ascending aorta**, not involving septal defects. - Presents with severe **cyanosis** and **cardiogenic shock** in the first days of life, requiring immediate intervention. *Aortic stenosis* - Involves **narrowing of the aortic valve** or **subvalvular/supravalvular areas**, not septal abnormalities. - Typically presents with **exercise intolerance**, **chest pain**, and **syncope** in older children, not early heart failure.

Question 82: Which of the following is NOT a sign of congestive cardiac failure in infants?

A. Gallop rhythm (S3)
B. Lack of weight gain
C. Large volume pulse (Correct Answer)
D. Peripheral cyanosis

Explanation: 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.

Question 83: Which of the following is NOT a cause of Long QT syndrome in children?

A. Romano Ward syndrome
B. Jervell and Lange-Nielsen Syndrome
C. Macrolide antibiotics
D. Holt-Oram Syndrome (Correct Answer)

Explanation: **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.

Question 84: A 1-year-old child presents with mental retardation, seizures, and facial angiofibromas. The child also experiences repeated episodes of syncope. An echocardiogram reveals a mass in the left ventricle causing intermittent obstruction. Pathologic examination of the resected mass demonstrates a cardiac rhabdomyoma. Which of the following lesions would this patient most likely also have?

A. Acoustic neuromas
B. Berry aneurysm
C. Cortical tubers (Correct Answer)
D. Meningiomas

Explanation: **Explanation:** The clinical triad of **mental retardation, seizures, and facial angiofibromas** (Adenoma sebaceum) is classic for **Tuberous Sclerosis Complex (TSC)**, an autosomal dominant neurocutaneous syndrome. 1. **Why Cortical Tubers is correct:** Tuberous Sclerosis is characterized by the growth of benign hamartomas in multiple organs. **Cardiac rhabdomyoma** is the most common primary cardiac tumor in infants and children, and approximately 50-80% of patients with these tumors have TSC. In the CNS, the hallmark lesions are **cortical tubers** (hamartomatous growths in the cortex) and subependymal nodules, which are the primary cause of seizures and cognitive impairment in these patients. 2. **Why other options are incorrect:** * **Acoustic neuromas & Meningiomas:** These are characteristic features of **Neurofibromatosis Type 2 (NF2)**, not Tuberous Sclerosis. NF2 typically presents with bilateral vestibular schwannomas. * **Berry aneurysm:** These are associated with **Autosomal Dominant Polycystic Kidney Disease (ADPKD)** and Coarctation of the Aorta. While TSC can involve the kidneys (angiomyolipomas), berry aneurysms are not a classic association. **High-Yield Clinical Pearls for NEET-PG:** * **TSC Genetics:** Mutations in *TSC1* (Hamartin) or *TSC2* (Tuberin) genes. * **Cardiac Rhabdomyoma:** Often regresses spontaneously; however, it can cause inflow/outflow obstruction or arrhythmias. * **Vogt’s Triad:** Seizures, mental retardation, and adenoma sebaceum (seen in <30% of cases). * **Dermatological markers:** Ash-leaf spots (hypopigmented macules - earliest sign), Shagreen patches (leathery skin on lower back), and Periungual fibromas (Koenen tumors). * **Renal involvement:** Bilateral Renal Angiomyolipomas.

Question 85: What is the most common benign tumor of the heart in children?

A. Rhabdomyoma (Correct Answer)
B. Myxoma
C. Fibroma
D. Lipoma

Explanation: **Explanation:** **Rhabdomyoma** is the most common primary cardiac tumor in infants and children, accounting for over 50% of cases. These are considered hamartomas rather than true neoplasms. They typically present as multiple, firm, grey-white nodules within the ventricular myocardium. A key clinical feature is their tendency for **spontaneous regression** over time, meaning surgical intervention is rarely required unless they cause significant outflow tract obstruction or refractory arrhythmias. **Analysis of Incorrect Options:** * **Myxoma:** This is the most common primary cardiac tumor in **adults**. In children, it is rare and usually associated with "Carney Complex" (spotty skin pigmentation, endocrine overactivity, and myxomas). * **Fibroma:** The second most common cardiac tumor in children. Unlike rhabdomyomas, fibromas are usually solitary, located in the interventricular septum, and **do not regress** spontaneously. They are associated with Gorlin syndrome. * **Lipoma:** These are slow-growing tumors composed of mature adipose tissue. While they can occur in the heart, they are significantly less common than rhabdomyomas in the pediatric age group. **High-Yield Clinical Pearls for NEET-PG:** * **Association:** Approximately 50–80% of children with cardiac rhabdomyoma have **Tuberous Sclerosis Complex (TSC)**. Conversely, rhabdomyoma is often the first clinical sign of TSC detected on fetal ultrasound. * **Histology:** Look for characteristic **"Spider Cells"** (large cells with central cytoplasm and radial granular extensions to the cell membrane). * **Location:** Most commonly found in the ventricles (intramural).

Question 86: All are true in Kawasaki disease except?

A. Exudative conjunctivitis (Correct Answer)
B. Pedal edema
C. Strawberry tongue
D. Thrombocytosis

Explanation: **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.

Question 87: What is the most common manifestation of rheumatic fever?

A. Arthritis (Correct Answer)
B. Carditis
C. Chorea
D. Nodules

Explanation: 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).

Question 88: How is congestive cardiac failure diagnosed in an infant?

A. Basal crepitations
B. Elevated jugular venous pressure
C. Pedal edema
D. Hepatomegaly (Correct Answer)

Explanation: 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.

Question 89: Which congenital heart defect (CHD) will lead to a left-to-right shunt, generally with cyanosis?

A. Anomalous origin of the left coronary artery from the pulmonary trunk
B. Patent ductus arteriosus without pulmonary hypertension
C. Total anomalous pulmonary venous connection (Correct Answer)
D. Ventricular septal defect

Explanation: **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.

Question 90: Modified Jones's criteria includes all the following as major criteria except?

A. Subcutaneous nodules
B. Arthritis
C. Fever (Correct Answer)
D. Carditis

Explanation: ### Explanation The diagnosis of **Acute Rheumatic Fever (ARF)** is based on the **Revised Jones Criteria (2015)**. To make a diagnosis, one requires evidence of a preceding Group A Streptococcal (GAS) infection plus either **two major criteria** or **one major and two minor criteria**. **Why Fever is the Correct Answer:** **Fever** is classified as a **Minor Criterion**, not a major one. In the 2015 revision, the threshold for fever as a minor criterion is ≥38.5°C for low-risk populations and ≥38°C for moderate-to-high-risk populations. **Analysis of Major Criteria (Incorrect Options):** The major criteria are remembered by the mnemonic **J♥NES**: * **J (Joints):** **Arthritis** (Option B). In low-risk groups, only *migratory polyarthritis* counts; in moderate/high-risk groups, *monoarthritis* or *polyarthralgia* are also included. * **♥ (Carditis):** **Carditis** (Option D). This includes clinical carditis or subclinical carditis detected via echocardiography (Doppler). * **N (Nodules):** **Subcutaneous nodules** (Option A). These are firm, painless, and typically found over bony prominences. * **E (Erythema Marginatum):** A pink, evanescent, non-pruritic macular rash with a serpiginous border. * **S (Sydenham Chorea):** Involuntary, purposeless movements; often a late manifestation. **NEET-PG High-Yield Pearls:** 1. **Minor Criteria:** Fever, Polyarthralgia, prolonged PR interval (on ECG), and elevated inflammatory markers (ESR ≥60 mm/hr or CRP ≥3 mg/dL). 2. **Essential Requirement:** Evidence of preceding GAS infection (Positive ASO titer, Anti-DNase B, or positive throat culture) is mandatory except in cases of isolated Sydenham chorea or insidious onset carditis. 3. **Most Common Manifestation:** Arthritis (earliest and most common). 4. **Most Serious Manifestation:** Carditis (leads to chronic valvular heart disease, most commonly Mitral Stenosis).

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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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Cardiology — MCQs

Cardiology — MCQs

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