Cardiology — MCQs

Cardiology UK Medical PG Practice Questions and MCQs

Question 21: A 38-year-old man presents with sudden onset severe "tearing" chest pain radiating to his back. His blood pressure is 180/100 mmHg in the right arm and 120/80 mmHg in the left arm. What is the most likely diagnosis?

A. Myocardial infarction
B. Aortic dissection (Correct Answer)
C. Pulmonary embolism
D. Pericarditis
E. Pneumothorax

Explanation: ***Aortic dissection***- This presentation of sudden, severe, **'tearing' chest pain** radiating to the back, combined with a **significant inter-arm blood pressure differential** (180/100 mmHg in right arm vs. 120/80 mmHg in left arm), is the classic triad for **aortic dissection**.- The BP differential arises when the dissection flap extends into and obstructs the origin of a major branch vessel, such as the **subclavian artery**, reducing perfusion to that limb.*Myocardial infarction*- Pain associated with **myocardial infarction (MI)** is typically described as crushing, pressure-like, or squeezing, often radiating to the left arm or jaw, which differs from the *tearing* quality described here.- While an MI can cause hemodynamic instability, it does not typically cause the **inter-arm systolic blood pressure differential** characteristic of aortic dissection.*Pulmonary embolism*- **Pulmonary embolism (PE)** is characterized by sudden onset **dyspnea**, hypoxemia, and pleuritic chest pain (sharp pain worsened by breathing), and is rarely described as *tearing*.- A **blood pressure differential** between the arms is not a typical clinical feature of pulmonary embolism.*Pericarditis*- **Pericarditis** typically causes sharp, pleuritic pain that is characteristically relieved by *sitting up and leaning forward* and worsened by *lying supine*.- It is not associated with severe, tearing pain radiating to the back or a **pulse deficit** in the peripheral circulation.*Pneumothorax*- A **pneumothorax** causes sudden, sharp, pleuritic chest pain and shortness of breath due to lung collapse.- This condition does not cause the specific **severe tearing pain** or the highly diagnostic **blood pressure differential** between the arms observed in this case.

Question 22: A 56-year-old man presents with progressive dyspnea and fatigue. Echocardiogram shows severe aortic regurgitation with LV end-systolic dimension 35mm and EF 50%. He is asymptomatic at rest. What is the most appropriate management?

A. Medical management
B. Aortic valve replacement (Correct Answer)
C. ACE inhibitors
D. Diuretics
E. Observation

Explanation: ***Aortic valve replacement*** - The presence of **severe aortic regurgitation** coupled with symptoms like **progressive dyspnea and fatigue** is a strong indication for **aortic valve replacement**, even if the patient reports being asymptomatic at rest, as these symptoms signify a need for intervention. - Current guidelines recommend surgical intervention for symptomatic patients with severe AR, regardless of LV function or dimensions, to prevent irreversible **left ventricular (LV) dysfunction** and improve prognosis. *Medical management* - While medical management can temporarily alleviate symptoms, it is **not definitive treatment** for severe, symptomatic aortic regurgitation and does not address the underlying valvular pathology. - Relying solely on medical management in this scenario would risk **progressive LV dysfunction** and potentially worse surgical outcomes if delayed. *ACE inhibitors* - **ACE inhibitors** are vasodilators that can reduce afterload and may be used in chronic AR to manage hypertension or as adjunctive therapy for heart failure symptoms. - However, they are **not a substitute for surgical correction** in severe, symptomatic AR, as they do not resolve the primary issue of valvular incompetence. *Diuretics* - **Diuretics** primarily manage symptoms of **fluid overload** and congestive heart failure by reducing preload, such as dyspnea and edema. - They provide **symptomatic relief** but do not treat the underlying severe aortic regurgitation or prevent its progression, making them inadequate as the primary management. *Observation* - **Observation** is generally reserved for patients with **asymptomatic severe aortic regurgitation** who have **preserved LV function (EF > 50%)** and normal LV dimensions (e.g., ESD < 50mm). - This patient, despite being asymptomatic at rest, presents with **progressive dyspnea and fatigue**, classifying him as symptomatic and thus requiring active intervention rather than observation.

Question 23: A 61-year-old man presents with sudden onset severe "tearing" chest pain radiating to his back. CT angiogram shows Stanford type B aortic dissection extending from the arch to the renal arteries. His BP is 165/95 mmHg. What is the most appropriate initial management?

A. Emergency surgical repair
B. Endovascular stent graft
C. Medical management with beta-blockers (Correct Answer)
D. Thrombolysis
E. Observation only

Explanation: ***Medical management with beta-blockers***- Stanford type B aortic dissection, which involves the aorta distal to the left subclavian artery, is typically managed medically in its uncomplicated form.- Initial management with **beta-blockers** aims to reduce **heart rate** and **blood pressure**, thereby decreasing shear stress on the aortic wall and preventing dissection propagation.*Emergency surgical repair*- **Emergency surgical repair** is the definitive treatment for **Stanford type A aortic dissection**, which involves the ascending aorta and is associated with a higher mortality risk requiring immediate intervention.- For **uncomplicated Stanford type B dissections**, surgery is generally reserved for complications such as rupture, organ malperfusion, or refractory pain, not as initial management.*Endovascular stent graft*- **Endovascular stent grafting (TEVAR)** is an important treatment option for **complicated Stanford type B dissections**, such as those with malperfusion, rupture, or expanding aneurysm, or in cases of failed medical management.- However, it is not the primary **initial management** for an uncomplicated acute type B dissection.*Thrombolysis*- **Thrombolysis** is indicated for conditions caused by acute thrombotic occlusion, such as **myocardial infarction** or **pulmonary embolism**.- It is **contraindicated** in acute aortic dissection as it can worsen the dissection, cause hemorrhage, and significantly increase mortality.*Observation only*- Aortic dissection is a **medical emergency** requiring prompt intervention, not mere observation.- Without active pharmacological management to control **blood pressure** and **heart rate**, the dissection can rapidly progress, rupture, or lead to end-organ ischemia.

Question 24: A 51-year-old man presents with progressive shortness of breath and fatigue. Echocardiogram shows severe aortic stenosis with valve area 0.6 cm² and mean gradient 55 mmHg. He is high surgical risk. What is the most appropriate treatment?

A. Medical management
B. Balloon aortic valvuloplasty
C. Transcatheter aortic valve replacement (Correct Answer)
D. Surgical aortic valve replacement
E. Heart transplantation

Explanation: ***Transcatheter aortic valve replacement*** - This is the standard intervention for symptomatic patients with **severe aortic stenosis** (AVA < 1.0 cm², Mean Gradient > 40 mmHg) who are determined to be at **high or prohibitive surgical risk**. - TAVR is less invasive than SAVR and provides significant improvement in symptoms and prognosis while avoiding the dangers associated with **open cardiac surgery** in a high-risk patient. *Medical management* - Medical therapy (e.g., diuretics) only manages symptoms of heart failure and does not treat the underlying **valve obstruction** in severe AS. - Intervention (SAVR or TAVR) is required for symptomatic severe AS to improve survival, as the condition carries a significantly **poor prognosis** without intervention. *Balloon aortic valvuloplasty* - **BAV** provides typically only temporary symptomatic relief and is associated with a high rate of **restenosis** within 6-12 months, making it unsuitable as a definitive long-term solution in adults. - It is generally reserved as a **bridge-to-TAVR/SAVR** intervention for unstable patients or for the treatment of **congenital AS** in pediatric patients. *Surgical aortic valve replacement* - SAVR is the traditional, definitive treatment for severe AS; however, it is contraindicated in this specific case because the patient has been classified as **high surgical risk**. - Due to the high risk of operative mortality or serious morbidity associated with open surgery, a less invasive option like **TAVR** is the preferred choice. *Heart transplantation* - Heart transplantation is reserved for patients with end-stage **refractory heart failure** who have exhausted all other treatment options. - Since the primary pathology is severe valvular disease, management involves replacing the abnormal valve, usually making heart transplantation **unnecessary** at this stage.

Question 25: A 64-year-old man presents with progressive dyspnea and ankle swelling. Chest X-ray shows cardiomegaly. Echocardiogram shows concentric LVH with preserved EF but impaired diastolic function. What is the most likely diagnosis?

A. Dilated cardiomyopathy
B. Heart failure with preserved ejection fraction (Correct Answer)
C. Hypertrophic cardiomyopathy
D. Restrictive cardiomyopathy
E. Ischemic cardiomyopathy

Explanation: ***Heart failure with preserved ejection fraction***

Question 26: A 53-year-old woman presents with progressive dyspnea and fatigue. Echocardiogram shows severe tricuspid regurgitation with elevated right heart pressures. Right heart catheterization shows mean PAP 48 mmHg. What is the most likely diagnosis?

A. Left heart failure
B. Pulmonary hypertension (Correct Answer)
C. Pulmonary embolism
D. COPD
E. Tricuspid valve disease

Explanation: ***Pulmonary hypertension*** - The definitive diagnostic criterion for **pulmonary hypertension** is a mean pulmonary artery pressure (PAP) exceeding 20 mmHg on **right heart catheterization**; 48 mmHg clearly confirms this diagnosis. - Progressive dyspnea and fatigue, coupled with signs of severe right heart strain (elevated right heart pressures and severe **tricuspid regurgitation**), are classic clinical manifestations of established pulmonary hypertension. *Left heart failure* - While **left heart failure (LHF)** is the most common cause of pulmonary hypertension (Group 2 PH), the elevated mean PAP (48 mmHg) is the direct, most likely diagnosis confirmed by RHC, irrespective of the underlying etiology. - LHF typically causes **pulmonary venous congestion**, which leads to post-capillary PH, but the presence of PH is the overarching diagnosis based strictly on the hemodynamic measurements. *Pulmonary embolism* - **Acute pulmonary embolism (PE)** typically presents acutely with sudden onset of dyspnea, often accompanied by chest pain or syncope, which contrasts with the progressive symptoms described here. - If this were **Chronic Thromboembolic Pulmonary Hypertension (CTEPH)**, it would fall under Group 4 PH, but the confirmed elevated mean PAP remains the official diagnosis. *COPD* - **Chronic Obstructive Pulmonary Disease (COPD)** is a common cause of Group 3 PH, driven by chronic hypoxia and pulmonary capillary destruction. - This diagnosis requires demonstrating obstructive ventilatory defects on **spirometry** and typically involves a significant smoking history, neither of which are provided in the scenario. *Tricuspid valve disease* - The severe **tricuspid regurgitation (TR)** is almost certainly secondary (functional), resulting from severe dilation and increased pressure of the right ventricle overloaded by the **pulmonary hypertension**. - Primary TR (e.g., due to endocarditis or congenital defects) is less common and would not necessarily cause such a high mean PAP unless associated with severe right heart failure.

Question 27: A 58-year-old man presents with progressive dyspnea and bilateral ankle swelling. Chest X-ray shows cardiomegaly and pulmonary edema. Echocardiogram shows EF 30% with global hypokinesis. Coronary angiogram is normal. What is the most likely diagnosis?

A. Ischemic cardiomyopathy
B. Dilated cardiomyopathy (Correct Answer)
C. Hypertrophic cardiomyopathy
D. Restrictive cardiomyopathy
E. Hypertensive heart disease

Explanation: ***Dilated cardiomyopathy*** - The presence of severe **systolic dysfunction** (EF 30%) and **global hypokinesis** indicates ventricular dilatation and failure, consistent with DCM. - The crucial finding is the **normal coronary angiogram**, which rules out ischemic heart disease, making non-ischemic dilated cardiomyopathy the most likely diagnosis. *Ischemic cardiomyopathy* - This diagnosis is ruled out because the **coronary angiogram is normal**, meaning the systolic dysfunction is not due to significant coronary artery disease. - Ischemic damage typically causes **regional wall motion abnormalities** corresponding to specific vascular territories, unlike the global hypokinesis reported here. *Hypertrophic cardiomyopathy* - HCM is characterized by unexplained **ventricular hypertrophy** (thickened walls) and primarily causes **diastolic dysfunction**, not global dilatation and severe systolic failure. - Although HCM can progress to systolic failure, the primary insult is hypertrophy, and the ventricle is typically non-dilated initially. *Restrictive cardiomyopathy* - Characterized by rigid, non-compliant ventricles, leading to severe **diastolic dysfunction** (impaired filling) but usually a **preserved Ejection Fraction (EF)**. - Imaging typically shows non-dilated ventricles and marked bi-atrial enlargement, which contrasts with the ventricular dilation implied by global hypokinesis and cardiomegaly. *Hypertensive heart disease* - Chronic hypertension initially leads to **concentric left ventricular hypertrophy** and **diastolic dysfunction** rather than primary global hypokinesis and severe systolic failure (DCM pattern). - While chronic hypertension can eventually cause secondary DCM, the primary structural diagnosis covering global systolic failure with dilation and normal coronaries is **dilated cardiomyopathy**.

Question 28: A 63-year-old man presents with progressive dyspnea and ankle swelling. Chest X-ray shows Kerley B lines and cardiomegaly. BNP is 2500 pg/mL. Echocardiogram shows EF 25%. What is the most appropriate initial medication?

A. Furosemide
B. ACE inhibitor (Correct Answer)
C. Beta-blocker
D. Spironolactone
E. Digoxin

Explanation: ***ACE inhibitor***- Given the diagnosis of **heart failure with reduced ejection fraction (HFrEF)** (EF 25%) and symptoms, an ACE inhibitor is a cornerstone of **guideline-directed medical therapy (GDMT)**. - It significantly improves **mortality and morbidity** in HFrEF by preventing cardiac remodeling and reducing both preload and afterload. *Furosemide*- While crucial for managing **symptoms of fluid overload** (dyspnea, ankle swelling, Kerley B lines) by reducing preload, **furosemide** does not improve long-term mortality or modify the disease progression in HFrEF.- It provides symptomatic relief, but it is not the *initial* disease-modifying medication for improving outcomes in HFrEF. *Beta-blocker*- **Beta-blockers** are also GDMT for HFrEF, improving mortality and morbidity, but they are generally initiated *after* an ACE inhibitor, once the patient is euvolemic and hemodynamically stable.- Initiating a beta-blocker too early in a patient with significant fluid overload can worsen symptoms or lead to acute decompensation due to negative inotropic effects. *Spironolactone*- **Spironolactone**, a mineralocorticoid receptor antagonist, is a GDMT for HFrEF that improves mortality, but it is typically added *after* an ACE inhibitor and beta-blocker in patients with persistent symptoms or reduced EF.- It is not considered the *initial* medication due to potential side effects like **hyperkalemia** and its role as an add-on therapy. *Digoxin*- **Digoxin** can improve symptoms and reduce hospitalizations in HFrEF, but it does not improve overall mortality.- It is typically reserved for patients who remain symptomatic despite optimal doses of ACE inhibitors, beta-blockers, and MRAs, or for rate control in atrial fibrillation with HFrEF, and has a narrow therapeutic window.

Question 29: A 59-year-old woman presents with progressive shortness of breath and fatigue. Echocardiogram shows severe mitral stenosis with valve area 0.8 cm². She is in atrial fibrillation. What is the most appropriate treatment?

A. Medical management only
B. Balloon mitral valvuloplasty (Correct Answer)
C. Mitral valve replacement
D. Mitral valve repair
E. Heart transplantation

Explanation: ***Balloon mitral valvuloplasty*** - For symptomatic patients with **severe mitral stenosis (MVA 0.8 cm ²)** who have favorable valve morphology, **percutaneous balloon mitral valvuloplasty (PBMV)** is the treatment of choice, offering high success and low complication rates. - The presence of **atrial fibrillation** is a common consequence of left atrial enlargement due to chronic mitral stenosis, and PBMV can alleviate the pressure overload. *Medical management only* - Although medical management (rate control for AF, diuretics) is used to manage symptoms, it does not address the underlying **severe mechanical obstruction** (MVA 0.8 cm²) and is insufficient as definitive therapy for symptomatic severe MS. - Delaying definitive intervention in symptomatic severe MS increases the risk of complications such as **pulmonary hypertension**, right heart failure, and systemic embolism. *Mitral valve replacement* - **Mitral valve replacement (MVR)** is reserved for patients with severe MS who have **unfavorable valve anatomy** (heavy calcification, significant subvalvular disease) or who fail PBMV. - Surgical intervention carries higher operative risk compared to PBMV for suitable candidates. *Mitral valve repair* - **Mitral valve repair** is typically the preferred surgical approach for **mitral regurgitation**, not usually for severe, chronic, purely stenotic rheumatic valve disease. - Repair in severe MS often yields inadequate results due to the extensive scarring and fusion of the valve leaflets and commissures. *Heart transplantation* - **Heart transplantation** is the definitive treatment only for end-stage refractory heart failure (NYHA Class III/IV) that is not amenable to standard surgical or interventional therapies. - This patient's presentation of severe mitral stenosis, while serious, does not indicate end-stage heart failure requiring transplantation as a primary treatment.

Question 30: A 68-year-old man presents with progressive dyspnea and bilateral ankle swelling. Echocardiogram shows severe tricuspid regurgitation with elevated right heart pressure. Right heart catheterization shows mean pulmonary artery pressure of 45 mmHg. What is the most likely diagnosis?

A. Left heart failure
B. Pulmonary hypertension (Correct Answer)
C. Tricuspid valve disease
D. Right heart failure
E. Pulmonary embolism

Explanation: ***Pulmonary hypertension***- The right heart catheterization result of a **mean pulmonary artery pressure (mPAP) of 45 mmHg** definitively diagnoses **pulmonary hypertension**, which is defined as an mPAP greater than 20 mmHg at rest.- The progressive **dyspnea** and **bilateral ankle swelling**, along with **severe tricuspid regurgitation** and elevated right heart pressure, are all clinical manifestations of the right ventricular dysfunction caused by the elevated pulmonary pressures.*Left heart failure*- While **left heart failure (LHF)** is a common *cause* of pulmonary hypertension (Group 2 PH), the question asks for the most likely *diagnosis* confirmed by the direct hemodynamic measurement.- LHF typically presents with signs of **left ventricular dysfunction** and elevated **pulmonary capillary wedge pressure (PCWP)**, which are not the primary diagnostic finding emphasized here.*Tricuspid valve disease*- The **severe tricuspid regurgitation (TR)** observed is typically a *secondary* condition, resulting from progressive dilation and dysfunction of the right ventricle due to chronic, severe **pulmonary hypertension**.- Primary tricuspid valve disease is less common and would not inherently explain the underlying **mean pulmonary artery pressure of 45 mmHg** as the root cause.*Right heart failure*- **Right heart failure (RHF)** is a *consequence* or clinical syndrome that develops when the right ventricle fails to pump blood effectively against a high afterload, as is the case in **pulmonary hypertension**.- The symptoms of **dyspnea** and **bilateral ankle swelling** are clinical signs of RHF, but the underlying elevated pressure state is the primary diagnosis.*Pulmonary embolism*- While a **pulmonary embolism** (especially chronic thromboembolic pulmonary hypertension or CTEPH) can lead to **pulmonary hypertension**, the most direct and specific diagnosis confirmed by the mPAP measurement of 45 mmHg is simply pulmonary hypertension.- Acute pulmonary embolism usually presents with a more rapid onset and distinct clinical features, and CTEPH is a *type* of pulmonary hypertension rather than the overarching diagnosis itself.

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Cardiology — MCQs

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