Cardiology Practice Questions

Q: Which score is calculated during performance of this test?

Duke score. ***Duke score (Duke Treadmill Score)*** - The image depicts a patient undergoing a **cardiac stress test** on a treadmill, and the **Duke Treadmill Score** is the primary score calculated during this test. - The Duke Treadmill Score is calculated using the formula: **Exercise time (minutes) - (5 × ST deviation in mm) - (4 × angina index)**. - It provides **prognostic information** for patients with suspected coronary artery disease and stratifies them into low, moderate, or high-risk categories. - This score integrates **exercise capacity, ECG changes, and angina symptoms** into a single prognostic value. *Bruce score (Bruce Protocol)* - The **Bruce Protocol** is the name of the standardized exercise testing protocol with progressive stages of increasing speed and incline. - It is the **method/protocol** used to conduct the test, not a score that is calculated. - While the test follows the Bruce Protocol, no "Bruce score" is derived from it. *Jones score (Jones Criteria)* - The **Jones criteria** are diagnostic criteria used for diagnosing **rheumatic fever**. - Completely unrelated to cardiac stress testing or exercise capacity assessment. *DeBakey score (DeBakey Classification)* - The **DeBakey classification** categorizes **aortic dissections** based on anatomical involvement. - Used in vascular surgery, not in exercise stress testing. *Wells score* - The **Wells score** is used for assessing the pretest probability of **deep vein thrombosis (DVT)** or **pulmonary embolism (PE)**. - Unrelated to cardiac stress testing or functional capacity evaluation.

Q: Which is correct about the ECG shown below?

Normal sinus rhythm. ***Normal sinus rhythm*** - Normal sinus rhythm is characterized by a **regular rate** (60–100 bpm), a P wave preceding every QRS complex, a **PR interval within the normal range (0.12–0.20 seconds)**, and narrow QRS complexes. - The ECG in the image shows a regular rhythm with 1:1 AV conduction, no dropped beats, and a PR interval that does not exceed 200 ms, consistent with normal sinus rhythm. *First degree heart block* - First-degree heart block is characterized by a **constantly prolonged PR interval** (greater than 0.20 seconds) without any dropped QRS complexes. - The ECG does not demonstrate a PR interval greater than 200 ms, ruling out first-degree heart block. *Second degree heart block, Wenckebach* - Wenckebach (Mobitz Type I) is characterized by **progressive PR interval lengthening** with each successive beat, followed by a **dropped QRS complex**. - The ECG does not show progressive PR prolongation or a dropped beat, ruling out Wenckebach block. *Second degree heart block, Mobitz Type II* - Mobitz Type II is characterized by **constant PR intervals** with sudden, unpredictable dropped QRS complexes without prior PR prolongation. - The ECG shows no dropped QRS complexes, ruling out Mobitz Type II. - Mobitz Type II typically occurs at the level of the His-Purkinje system and often progresses to complete heart block. *2:1 block* - A 2:1 block implies that **every other P wave is blocked**, resulting in two P waves for every QRS complex. - The ECG shows all P waves conducting to the ventricles, which is not consistent with a fixed 2:1 conduction ratio. *Third degree heart block* - Third-degree (complete) heart block involves **complete dissociation** between atrial and ventricular activity, meaning P waves and QRS complexes occur independently. - This ECG demonstrates a clear and consistent relationship between the P waves and QRS complexes, ruling out complete AV dissociation.

Q: Which device is shown here?

Holter. ***Holter*** - The image shows a **small, portable device** connected to the chest via several **electrodes**, designed to record the heart's electrical activity over an extended period. - This setup is characteristic of a **Holter monitor**, used for continuous ambulatory electrocardiography to detect intermittent arrhythmias or other cardiac events. - Holter monitors provide **continuous 24-48 hour recording** without patient activation. *IABP* - An **Intra-Aortic Balloon Pump** (IABP) is an invasive device typically inserted into the aorta via a peripheral artery, with its effects seen on hemodynamic monitoring rather than external chest electrodes. - It is used for temporary mechanical circulatory support in patients with severe heart failure or cardiogenic shock, not for ambulatory ECG recording. *ICD* - An **Implantable Cardioverter-Defibrillator** (ICD) is a surgically implanted device, usually beneath the skin in the chest or abdomen, with leads going into the heart. - It is used to detect and correct life-threatening arrhythmias and would not be visible externally as a connected portable device with electrodes. *AED* - An **Automated External Defibrillator** (AED) is a portable device used in emergency situations to deliver an electrical shock to restore normal heart rhythm in cases of sudden cardiac arrest. - It consists of large pads applied to the chest for defibrillation and is not used for continuous, long-term monitoring as depicted. *Implantable loop recorder* - An **implantable loop recorder (ILR)** is a subcutaneously implanted device inserted under the skin of the chest, with no external electrodes or leads visible on the body surface. - It cannot resemble the externally worn device with chest electrodes and a waistband-clipped recorder shown in the image.

Q: An 80-year-old woman has had several episodes of dizziness and recently fell, sustaining a hip fracture. The ECG shown demonstrates complete (third-degree) AV block with marked bradycardia. She is hemodynamically stable, and evaluation reveals no reversible cause such as medication toxicity, electrolyte disturbance, or acute myocardial ischemia. What is the next best step in management?

Implant a permanent pacemaker. Symptomatic acquired complete AV block without a reversible cause is an indication for permanent pacemaker implantation. Her preceding dizziness and fall are consistent with symptoms caused by bradycardia, even though she is currently hemodynamically stable. A temporary transvenous pacemaker is generally reserved for hemodynamic instability, an inadequate escape rhythm, or circumstances in which definitive permanent pacing cannot be performed promptly; it is not routinely required solely as a bridge to noncardiac surgery. Atropine may be attempted as short-term therapy in selected unstable patients but is often ineffective in infranodal complete AV block and is not definitive treatment. An ICD is not indicated in the absence of a ventricular tachyarrhythmia or another sudden-death prevention indication. Hip fracture repair should follow appropriate cardiac stabilization and coordination of definitive pacing.

Q: Comment on the diagnosis of the ECG tracing shown below:

Second degree AV block type 1. ***Second degree AV block type 1*** - The ECG shows progressive **PR interval lengthening** until a QRS complex is dropped, which is characteristic of **second-degree AV block type 1**, also known as Wenckebach. - This type of block is typically located within the **AV node (intranodal)**, hence QRS complexes are usually narrow. Note: definitive anatomic localization (intranodal vs infranodal) requires electrophysiologic study and cannot be confirmed from the surface ECG alone. *First degree AV block, intranodal* - First-degree AV block is characterized by a **consistently prolonged PR interval** (greater than 0.20 seconds) without any dropped QRS complexes. - The tracing clearly demonstrates dropped beats and variable PR intervals, ruling out a first-degree block. *Second degree AV block type 2, infranodal* - Second-degree AV block type 2 involves **sudden, unexpected dropped QRS complexes** without prior PR interval lengthening. - This type of block is often **infranodal** (below the AV node) and associated with wider QRS complexes and a higher risk of progression to complete heart block. *Second degree AV block type 2, intranodal* - While second-degree AV block type 2 can theoretically occur intranodally, it is much less common, and the hallmark feature of type 2 (sudden dropped beats without PR lengthening) is not present here. - The variable PR interval followed by a dropped beat clearly points to Type 1 (Wenckebach) phenomenon. *Third degree AV block* - Third-degree AV block (complete heart block) is characterized by **complete dissociation** between atrial and ventricular activity, with P waves and QRS complexes occurring independently. - In this tracing, there is a clear relationship between P waves and QRS complexes (progressive PR lengthening), ruling out complete heart block.

Q: 274. A young athlete was found to have hypertrophic cardiomyopathy during testing for a competitive sport. Which of the following maneuvers will increase the murmur?

Valsalva maneuver. **Valsalva maneuver** - The **Valsalva maneuver** reduces **preload** by decreasing venous return to the heart. - A decrease in preload reduces the left ventricular chamber size, which in turn exacerbates the **left ventricular outflow tract (LVOT) obstruction** characteristic of hypertrophic cardiomyopathy (HCM), thereby **increasing the intensity of the murmur**. *Handgrip* - **Handgrip** is an isometric exercise that leads to an increase in **afterload** and **peripheral vascular resistance**. - Increased afterload causes the left ventricle to eject blood against higher pressure, which **enlarges the left ventricular chamber** and **reduces the LVOT obstruction**, thus **decreasing the intensity of the murmur** in HCM. *Squatting* - **Squatting** increases both **preload** (due to increased venous return) and **afterload** (due to increased peripheral vascular resistance). - The increased preload and afterload lead to an **increased left ventricular volume**, which **reduces the LVOT obstruction** and therefore **decreases the intensity of the murmur** in HCM. *Passive leg raise* - **Passive leg raise** increases **preload** by increasing venous return to the heart from the lower extremities. - The increased preload leads to an **increased left ventricular chamber size**, which **reduces the LVOT obstruction** and therefore **decreases the intensity of the murmur** in HCM. *Leaning forward* - Leaning forward during auscultation is typically used to better hear **aortic regurgitation murmurs**, as it brings the aorta closer to the chest wall. - This maneuver does not significantly alter **cardiac preload or afterload** in a way that would consistently increase the murmur of hypertrophic cardiomyopathy.

Question 1

Which score is calculated during performance of this test?

Accepted Answer

Duke score

Answer

Bruce score

Answer

Jones score

Answer

DeBakey score

Answer

Wells score

Question 2

Which is correct about the ECG shown below?

Accepted Answer

Normal sinus rhythm

Answer

Third degree heart block

Answer

2:1 block

Answer

Second degree heart block, Wenckebach

Answer

First degree heart block

Answer

Second degree heart block, Mobitz Type II

Question 3

What is not recommended while wearing this cardiac device?

Accepted Answer

Taking a bath

Answer

Use of cell-phone

Answer

Consumption of energy drinks

Answer

Consumption of coffee

Answer

Exercise

Question 4

Which device is shown here?

Accepted Answer

Holter

Answer

AED

Answer

IABP

Answer

ICD

Answer

Implantable loop recorder

Question 5

Which of the following describes the marked ECG finding?

Accepted Answer

Electrical alternans

Answer

T-wave alternans

Answer

Electromechanical dissociation

Answer

All of the above

Answer

Pulsus alternans

Question 6

A patient complains of exertional syncope. He gives history of sudden death of his elder brother during a football game. Which of the following ECG findings is seen here?

Accepted Answer

Broad QRS with short PR with delta wave

Answer

Broad QRS with prolonged PR with epsilon wave

Answer

Narrow QRS with short PR with left ventricular hypertrophy

Answer

Narrow QRS with prolonged PR with Osborn wave

Question 7

An 80-year-old woman has had several episodes of dizziness and recently fell, sustaining a hip fracture. The ECG shown demonstrates complete (third-degree) AV block with marked bradycardia. She is hemodynamically stable, and evaluation reveals no reversible cause such as medication toxicity, electrolyte disturbance, or acute myocardial ischemia. What is the next best step in management?

Accepted Answer

Implant a permanent pacemaker

Answer

Proceed directly to hip fracture repair without pacing

Answer

Insert a temporary transvenous pacemaker routinely before hip surgery

Answer

Implant an implantable cardioverter-defibrillator

Answer

Administer atropine as definitive therapy

Question 8

Comment on the diagnosis of the ECG tracing shown below:

Accepted Answer

Second degree AV block type 1

Answer

First degree AV block, intranodal

Answer

Second degree AV block type 2, intranodal

Answer

Second degree AV block type 2, infranodal

Answer

Third degree AV block

Question 9

A 16-year-old boy presents with recurrent episodes of light headedness followed by syncope in school assembly. ECG was done on arrival to hospital. What is the diagnosis?

Accepted Answer

Wolff-Parkinson-White syndrome

Answer

ECG is normal, look for other causes of syncope

Answer

Left ventricular hypertrophy

Answer

VT storm

Answer

Long QT syndrome

Question 10

274. A young athlete was found to have hypertrophic cardiomyopathy during testing for a competitive sport. Which of the following maneuvers will increase the murmur?

Accepted Answer

Valsalva maneuver

Answer

Handgrip

Answer

Squatting

Answer

Leaning forward

Answer

Passive leg raise

Cardiology — MCQs

Cardiology — MCQs

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