Cardiovascular System Flashcards
A 65-year-old male presents with exertional chest pain. Which initial test is most appropriate?
A. Echocardiography
B. Exercise stress test
C. Coronary angiography
D. Chest X-ray
B. Exercise stress test
Explanation:
For a 65-year-old male with exertional chest pain, the most appropriate initial test to evaluate for stable ischemic heart disease (IHD) is an exercise stress test (if no contraindications exist).
Why?
• Exertional chest pain suggests stable angina, which is typically due to coronary artery disease (CAD).
• Exercise stress testing evaluates for myocardial ischemia by detecting ST-segment changes, symptoms, or hemodynamic abnormalities during exertion.
• It is useful for risk stratification and guiding further testing or management.
Why not the other options?
A. Echocardiography → Useful for assessing structural heart disease and left ventricular function but not the first-line test for stable angina unless there are signs of heart failure or valvular disease.
C. Coronary angiography → The gold standard for diagnosing CAD, but it is invasive and not the initial test. It is usually reserved for high-risk patients or those with abnormal stress test results.
D. Chest X-ray → Can assess for other causes of chest pain (e.g., pneumonia, heart failure, aortic aneurysm) but is not helpful in diagnosing myocardial ischemia.
Which physical examination finding is most indicative of heart failure?
A. Elevated jugular venous pressure
B. Loud S1 heart sound
C. Peripheral cyanosis
D. Bounding pulses
A. Elevated jugular venous pressure
Explanation:
Elevated jugular venous pressure (JVP) is the most indicative physical exam finding of heart failure (HF), particularly right-sided or decompensated heart failure.
• JVP reflects right atrial pressure, which increases in heart failure with volume overload due to impaired right ventricular function.
• Key features of elevated JVP:
• Prominent jugular venous distension (JVD) seen at >45° inclination.
• Positive hepatojugular reflux (JVP rises with abdominal pressure).
• Often associated with peripheral edema, ascites, and hepatomegaly.
Why not the other options?
B. Loud S1 heart sound → Suggests mitral stenosis rather than heart failure. In HF, S3 or S4 gallops are more characteristic.
C. Peripheral cyanosis → Can be seen in low-output heart failure, but it is not specific and can also occur in other conditions (e.g., shock, respiratory diseases).
D. Bounding pulses → More indicative of high-output states (e.g., aortic regurgitation, sepsis) rather than typical heart failure. HF often presents with weak pulses due to reduced cardiac output.
What is the primary purpose of measuring B-type natriuretic peptide (BNP) levels?
A. Diagnosing myocardial infarction
B. Assessing renal function
C. Evaluating heart failure severity
D. Detecting arrhythmias
C. Evaluating heart failure severity
Explanation:
B-type natriuretic peptide (BNP) and its precursor N-terminal pro-BNP (NT-proBNP) are key biomarkers for diagnosing and assessing the severity of heart failure (HF).
• BNP is released from ventricular myocytes in response to increased wall stress due to volume overload or pressure overload.
Functions of BNP:
• Promotes natriuresis and diuresis (increases sodium and water excretion).
• Causes vasodilation and reduces afterload.
• Inhibits the renin-angiotensin-aldosterone system (RAAS) to counteract fluid retention.
Clinical Uses:
✅ Diagnosis of HF:
• BNP > 100 pg/mL or NT-proBNP > 300 pg/mL suggests HF (though values vary by age and renal function).
• Helps differentiate cardiac vs. non-cardiac causes of dyspnea (e.g., pulmonary disease).
✅ Monitoring HF severity and prognosis:
• Higher BNP levels indicate worsening HF and poor prognosis.
• Declining BNP levels correlate with treatment response.
Why not the other options?
A. Diagnosing myocardial infarction (MI) → Troponins (Troponin I or T) are the preferred biomarkers for MI diagnosis. BNP may be elevated in MI due to ventricular strain but is not specific for MI.
B. Assessing renal function → Creatinine and glomerular filtration rate (GFR) are used for renal function assessment. BNP may be falsely elevated in renal failure due to decreased clearance.
D. Detecting arrhythmias → Arrhythmias are best diagnosed with ECG or Holter monitoring. BNP may be elevated in atrial fibrillation but is not used for arrhythmia detection.
Which of the following is a major modifiable risk factor for cardiovascular disease?
A. Age
B. Gender
C. Hypertension
D. Family history
C. Hypertension
Explanation:
Hypertension (high blood pressure) is one of the most important modifiable risk factors for cardiovascular disease (CVD).
• Chronic hypertension leads to:
• Endothelial damage → Promotes atherosclerosis.
• Left ventricular hypertrophy (LVH) → Increases risk of heart failure, arrhythmias, and sudden cardiac death.
• Increased afterload → Can cause ischemic heart disease and stroke.
• Arterial stiffness and renal damage → Contributes to chronic kidney disease (CKD) and peripheral arterial disease (PAD).
Other modifiable CVD risk factors include:
• Dyslipidemia (high LDL, low HDL, high triglycerides)
• Diabetes mellitus
• Smoking
• Obesity and physical inactivity
• Poor diet (high in sodium, saturated fats, and processed foods)
Why not the other options?
A. Age → A major risk factor, but non-modifiable. CVD risk increases with age due to vascular aging and arterial stiffness.
B. Gender → Males have a higher risk of CVD at younger ages, but postmenopausal women catch up. Not modifiable.
D. Family history → Genetic predisposition plays a role, but this is non-modifiable. However, lifestyle changes can still reduce overall risk.
A patient reports sudden onset of palpitations and lightheadedness. Which diagnostic test is most appropriate initially?
A. Echocardiogram
B. Electrocardiogram (ECG)
C. Holter monitor
D. Tilt-table test
B. Electrocardiogram (ECG)
Explanation:
An ECG is the most appropriate initial test for a patient with sudden onset of palpitations and lightheadedness because it provides an immediate assessment of cardiac rhythm and can identify arrhythmias such as:
• Atrial fibrillation (AF)
• Supraventricular tachycardia (SVT)
• Ventricular tachycardia (VT)
• Bradyarrhythmias (e.g., heart block, sick sinus syndrome)
If the arrhythmia is ongoing, an ECG can capture it in real-time. However, if symptoms are intermittent, further monitoring may be required.
Why not the other options?
A. Echocardiogram → Useful for detecting structural heart disease (e.g., valvular disorders, cardiomyopathy), but it is not the first-line test for acute palpitations.
C. Holter monitor → A 24-48 hour ambulatory ECG monitor, helpful if the arrhythmia is intermittent and not captured on an initial ECG. However, it is not the immediate first-line test for sudden palpitations.
D. Tilt-table test → Used for evaluating vasovagal syncope or orthostatic hypotension, not for sudden palpitations.
Which symptom is most characteristic of peripheral arterial disease?
A. Intermittent claudication
B. Orthopnea
C. Nocturnal dyspnea
D. Palpitations
A. Intermittent claudication
Explanation:
Peripheral arterial disease (PAD) is caused by atherosclerotic narrowing of peripheral arteries, most commonly affecting the lower extremities.
• Intermittent claudication is the hallmark symptom of PAD. It refers to exercise-induced muscle pain or cramping (usually in the calves, thighs, or buttocks) that is relieved by rest.
• This occurs due to insufficient blood flow to the muscles during exertion, leading to ischemic pain.
Why not the other options?
B. Orthopnea → Difficulty breathing while lying flat, commonly seen in heart failure due to pulmonary congestion, not PAD.
C. Nocturnal dyspnea → Seen in paroxysmal nocturnal dyspnea (PND), a symptom of congestive heart failure (CHF) due to fluid redistribution and pulmonary congestion, not PAD.
D. Palpitations → Suggestive of arrhythmias (e.g., atrial fibrillation, supraventricular tachycardia) rather than PAD.
What is the most common cause of syncope in young adults?
A. Cardiac arrhythmias
B. Vasovagal syncope
C. Orthostatic hypotension
D. Aortic stenosis
B. Vasovagal syncope
Which of the following is a non-modifiable risk factor for cardiovascular disease?
A. Smoking
B. Diabetes mellitus
C. Age
D. Hyperlipidemia
C. Age
A 50-year-old female presents with fatigue and dyspnea on exertion. Which test would best assess her left ventricular function?
A. Chest X-ray
B. Echocardiography
C. Electrocardiogram (ECG)
D. Cardiac MRI
B. Echocardiography
Which lifestyle modification has the greatest impact on reducing cardiovascular risk?
A. Reducing dietary sodium
B. Increasing physical activity
C. Smoking cessation
D. Moderating alcohol intake
C. Smoking cessation
What is the primary goal of lipid-lowering therapy in cardiovascular disease prevention?
A. Increase HDL cholesterol
B. Decrease LDL cholesterol
C. Lower triglycerides
D. Reduce total cholesterol
B. Decrease LDL cholesterol
Which of the following is a common side effect of beta-blockers?
A. Bradycardia
B. Hyperkalemia
C. Cough
D. Peripheral edema
A. Bradycardia
Explanation:
Beta-blockers (e.g., metoprolol, atenolol, propranolol, carvedilol) reduce heart rate by blocking beta-adrenergic receptors in the heart, leading to decreased sinoatrial (SA) node activity.
Common side effects of beta-blockers include:
• Bradycardia (slow heart rate) → Due to reduced sympathetic stimulation of the heart.
• Hypotension → From decreased cardiac output.
• Fatigue → Due to reduced cardiac output and CNS effects.
• Bronchospasm (in non-selective beta-blockers like propranolol) → Caution in asthma/COPD patients.
• Masking of hypoglycemia symptoms in diabetics.
Why not the other options?
B. Hyperkalemia → More commonly associated with ACE inhibitors, ARBs, potassium-sparing diuretics (e.g., spironolactone), but beta-blockers can slightly raise potassium levels by reducing renin secretion.
C. Cough → A characteristic side effect of ACE inhibitors (e.g., lisinopril, enalapril) due to increased bradykinin levels. Beta-blockers do not cause this.
D. Peripheral edema → More commonly seen with calcium channel blockers (CCBs) (e.g., amlodipine) due to vasodilation and fluid retention. Beta-blockers do not typically cause peripheral edema.
A patient with a history of myocardial infarction presents with new-onset heart failure. Which medication class is most beneficial in reducing mortality?
A. Calcium channel blockers
B. Diuretics
C. ACE inhibitors
D. Nitrates
C. ACE inhibitors
Which feature on an electrocardiogram (ECG) suggests left ventricular hypertrophy (LVH)?
A. ST-segment depression and T-wave inversion
B. Low voltage QRS complexes
C. Peaked P waves in lead II
D. Prolonged QT interval
A. ST-segment depression and T-wave inversion
Explanation:
Left ventricular hypertrophy (LVH) on an electrocardiogram (ECG) is typically associated with:
1. Increased QRS Voltage – Tall R waves in left-sided leads (V5, V6, I, aVL) and deep S waves in right-sided leads (V1, V2) (e.g., Sokolow-Lyon or Cornell criteria).
2. ST-segment depression and T-wave inversion (LV strain pattern) – This is seen in leads with tall R waves (typically V5, V6, I, aVL). It reflects subendocardial ischemia due to increased myocardial oxygen demand.
Why not the other options?
B. Low voltage QRS complexes → More characteristic of pericardial effusion, obesity, or amyloidosis, not LVH.
C. Peaked P waves in lead II → Suggests right atrial enlargement (P pulmonale), seen in conditions like pulmonary hypertension or COPD.
D. Prolonged QT interval → Associated with electrolyte imbalances, congenital long QT syndrome, or medications, not LVH.
What is the most common cause of sudden cardiac death in adults?
A. Aortic dissection
B. Pulmonary embolism
C. Coronary artery disease
D. Hypertrophic cardiomyopathy
C. Coronary artery disease
Explanation:
Coronary artery disease (CAD) is the most common cause of sudden cardiac death (SCD) in adults, accounting for up to 80% of cases. The primary mechanism is usually ventricular arrhythmia (e.g., ventricular tachycardia or fibrillation) triggered by acute myocardial ischemia or prior myocardial infarction (MI)-related scar tissue.
Why not the other options?
A. Aortic dissection → Can cause sudden death due to rupture or tamponade, but it is less common than CAD. It is often seen in hypertension, connective tissue disorders (e.g., Marfan syndrome), or bicuspid aortic valve disease.
B. Pulmonary embolism (PE) → A major cause of sudden death but not as frequent as CAD. It typically presents with sudden dyspnea, hypotension, and right ventricular failure.
D. Hypertrophic cardiomyopathy (HCM) → A leading cause of SCD in young athletes, but in the general adult population, CAD is far more common.
Which of the following is the most specific biomarker for diagnosing acute myocardial infarction (AMI)?
A. Creatine kinase-MB (CK-MB)
B. Troponin I or T
C. Myoglobin
D. Lactate dehydrogenase (LDH)
B. Troponin I or T
Explanation:
Cardiac troponins (Troponin I and Troponin T) are the most specific and sensitive biomarkers for diagnosing acute myocardial infarction (AMI).
• Troponins are highly specific to cardiac muscle and are not significantly found in other tissues, unlike CK-MB or LDH.
• Troponins rise within 3–6 hours, peak at 12–24 hours, and remain elevated for 7–10 days, allowing for late detection of AMI.
Why not the other options?
A. Creatine kinase-MB (CK-MB) → Previously used for AMI diagnosis but is less specific because it is also found in skeletal muscle. It rises in 3–6 hours, peaks at 12–24 hours, and normalizes within 2–3 days. Useful for detecting reinfarction.
C. Myoglobin → Rises earlier than troponins (within 1–2 hours) but lacks specificity because it is present in skeletal muscle injuries as well.
D. Lactate dehydrogenase (LDH) → Non-specific and not commonly used for AMI diagnosis today. LDH-1/LDH-2 ratio elevation was historically used but is now obsolete.
Which heart sound is most commonly associated with heart failure due to volume overload?
A. S1
B. S2
C. S3
D. S4
C. S3
Explanation:
The S3 heart sound is most commonly associated with heart failure due to volume overload.
• It occurs during early diastole (just after S2) due to rapid ventricular filling against a dilated, noncompliant ventricle.
• It is often referred to as a “ventricular gallop” and is best heard with the bell of the stethoscope at the apex (left-sided) or lower left sternal border (right-sided), in the left lateral decubitus position.
• S3 is common in conditions like systolic heart failure, mitral regurgitation, and high-output states (e.g., anemia, thyrotoxicosis).
Why not the other options?
A. S1 → Represents mitral and tricuspid valve closure and is not directly related to heart failure.
B. S2 → Represents aortic and pulmonary valve closure; abnormalities in S2 splitting can be seen in conditions like pulmonary hypertension or aortic stenosis but are not directly indicative of volume overload.
D. S4 → Occurs in late diastole due to atrial contraction against a stiff, noncompliant ventricle. It is associated with diastolic dysfunction (e.g., left ventricular hypertrophy, hypertrophic cardiomyopathy, hypertension) rather than volume overload.
A patient with exertional dyspnea and an early diastolic murmur heard at the left sternal border most likely has which valvular disease?
A. Aortic stenosis
B. Aortic regurgitation
C. Mitral stenosis
D. Mitral regurgitation
B. Aortic regurgitation
Explanation:
An early diastolic murmur heard at the left sternal border is characteristic of aortic regurgitation (AR).
• Aortic regurgitation (AR) occurs due to incompetent aortic valve closure, allowing blood to flow back from the aorta into the left ventricle during diastole.
• The murmur is high-pitched, blowing, and decrescendo, best heard at the left sternal border (3rd–4th intercostal space) with the patient sitting up, leaning forward, and in full expiration.
Why not the other options?
A. Aortic stenosis → Causes a systolic ejection murmur best heard at the right upper sternal border, radiating to the carotids.
C. Mitral stenosis → Produces a low-pitched, rumbling diastolic murmur best heard at the apex with the bell in the left lateral decubitus position.
D. Mitral regurgitation → Causes a holosystolic murmur best heard at the apex, radiating to the axilla.
Which test is best for detecting silent ischemia in an asymptomatic patient with multiple cardiovascular risk factors?
A. Resting ECG
B. Coronary angiography
C. Exercise stress test
D. Cardiac MRI
C. Exercise stress test
Explanation:
An exercise stress test is the best initial test for detecting silent ischemia in an asymptomatic patient with multiple cardiovascular risk factors.
• Silent ischemia refers to myocardial ischemia without anginal symptoms.
• Exercise stress testing helps unmask ischemia by increasing myocardial oxygen demand, revealing ST-segment changes indicative of coronary artery disease (CAD).
• It is particularly useful in patients with diabetes, hypertension, dyslipidemia, or a strong family history of CAD, who are at higher risk for silent ischemia.
Why not the other options?
A. Resting ECG → May show prior infarction or nonspecific changes but is often normal in silent ischemia.
B. Coronary angiography → The gold standard for diagnosing CAD, but it is invasive and not recommended for asymptomatic screening.
D. Cardiac MRI → Useful for assessing myocardial viability and ischemia, but it is not the first-line test for asymptomatic screening.
Which antihypertensive drug class is preferred in a patient with hypertension and chronic kidney disease?
A. Beta-blockers
B. Calcium channel blockers
C. ACE inhibitors or ARBs
D. Thiazide diuretics
C. ACE inhibitors or ARBs
Explanation:
In patients with hypertension and chronic kidney disease (CKD), ACE inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are the preferred antihypertensive drug class because they:
• Reduce proteinuria and slow the progression of CKD.
• Lower glomerular pressure by inhibiting the renin-angiotensin-aldosterone system (RAAS).
• Provide cardiovascular protection, which is crucial in CKD patients with high cardiovascular risk.
Why not the other options?
A. Beta-blockers → Can be used for cardiovascular protection but are not first-line for CKD-related hypertension. Some beta-blockers (e.g., atenolol) are renally excreted and require dose adjustment.
B. Calcium channel blockers (CCBs) → Effective for blood pressure control, but they do not reduce proteinuria or provide nephroprotection like ACEIs/ARBs.
D. Thiazide diuretics → Useful in mild hypertension, but they are less effective in advanced CKD (eGFR <30 mL/min/1.73m²) and can lead to electrolyte imbalances. Loop diuretics (e.g., furosemide) are preferred in CKD patients with volume overload.
A young athlete collapses suddenly during exertion. The most likely cause is:
A. Atrial fibrillation
B. Hypertrophic cardiomyopathy
C. Pulmonary hypertension
D. Mitral valve prolapse
B. Hypertrophic cardiomyopathy
Explanation:
Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden cardiac death (SCD) in young athletes, often due to ventricular arrhythmias triggered by exertion.
Pathophysiology:
• HCM is an autosomal dominant genetic disorder characterized by asymmetric left ventricular hypertrophy, usually affecting the interventricular septum.
• This leads to left ventricular outflow tract (LVOT) obstruction, diastolic dysfunction, and an increased risk of ventricular tachyarrhythmias.
Clinical Features:
• Syncope, dyspnea, or palpitations during exertion.
• Sudden cardiac death (SCD) in young athletes, often without prior symptoms.
• Systolic murmur that increases with Valsalva or standing (due to reduced preload).
• Diagnosis is confirmed by echocardiography (showing asymmetric LV hypertrophy, often >15 mm).
Why not the other options?
A. Atrial fibrillation → Can occur in HCM patients but is not the usual cause of sudden collapse in young athletes.
C. Pulmonary hypertension → Can cause exertional dyspnea and syncope but is not the most common cause of sudden cardiac death in athletes.
D. Mitral valve prolapse (MVP) → Usually benign, though rarely associated with arrhythmias, it does not typically cause sudden cardiac death in young athletes.
Which arrhythmia is most commonly associated with chronic hypertension?
A. Atrial fibrillation
B. Ventricular tachycardia
C. Supraventricular tachycardia
D. Atrioventricular block
A. Atrial fibrillation
Explanation:
Atrial fibrillation (AF) is the most common arrhythmia associated with chronic hypertension.
Hypertension leads to:
• Left ventricular hypertrophy (LVH) → Increased left atrial pressure due to diastolic dysfunction.
• Left atrial enlargement → Structural and electrical remodeling that promotes atrial fibrillation.
• Increased atrial fibrosis → Creates reentry circuits, increasing the risk of AF.
AF in Hypertension:
• Increases the risk of stroke and heart failure.
• Manifests as palpitations, fatigue, or dyspnea, but can also be asymptomatic.
• Diagnosed with irregularly irregular rhythm on ECG (no distinct P waves, irregular R-R intervals).
Why not the other options?
B. Ventricular tachycardia (VT) → More common in ischemic heart disease or cardiomyopathy, not primary hypertension.
C. Supraventricular tachycardia (SVT) → More often due to accessory pathways (e.g., AVNRT, WPW syndrome) rather than hypertension.
D. Atrioventricular (AV) block → More associated with fibrosis, ischemia, or medication effects (e.g., beta-blockers, calcium channel blockers) rather than hypertension.
Which physical examination finding is most consistent with severe aortic stenosis?
A. Bounding pulses
B. Wide pulse pressure
C. Pulsus parvus et tardus
D. Collapsing pulse
C. Pulsus parvus et tardus
Explanation:
Pulsus parvus et tardus (weak and delayed carotid pulse) is the classic physical exam finding in severe aortic stenosis (AS).
• “Parvus” = weak pulse (low stroke volume due to fixed aortic obstruction).
• “Tardus” = delayed upstroke (slow rise in carotid pulse due to prolonged left ventricular systole).
Other Key Findings in Severe Aortic Stenosis:
• Harsh, crescendo-decrescendo systolic murmur best heard at the right upper sternal border, radiating to the carotids.
• Soft or absent S2 (due to immobile aortic valve).
• Delayed carotid upstroke (tardus).
Why not the other options?
A. Bounding pulses → Seen in conditions with high stroke volume and rapid ejection, such as aortic regurgitation, patent ductus arteriosus, or hyperthyroidism, not AS.
B. Wide pulse pressure → Common in aortic regurgitation, not aortic stenosis, which typically has a narrow pulse pressure due to reduced stroke volume.
D. Collapsing pulse (Water hammer pulse) → Strong peripheral pulses that collapse rapidly, characteristic of aortic regurgitation, not aortic stenosis.
A patient presents with chest pain that is worse when lying down and relieved by sitting up and leaning forward. Which diagnosis is most likely?
A. Myocardial infarction
B. Aortic dissection
C. Pericarditis
D. Gastroesophageal reflux disease (GERD)
C. Pericarditis
Which of the following is a common cause of secondary hypertension?
A. Essential hypertension
B. Pheochromocytoma
C. Atherosclerosis
D. Atrial fibrillation
B. Pheochromocytoma
What is the most common cause of heart failure with preserved ejection fraction (HFpEF)?
A. Coronary artery disease
B. Long-standing hypertension
C. Mitral regurgitation
D. Aortic dissection
B. Long-standing hypertension
A patient presents with unilateral leg swelling and pain. Which test is most appropriate to diagnose deep vein thrombosis (DVT)?
A. D-dimer test
B. Venous duplex ultrasound
C. Chest X-ray
D. Electrocardiogram (ECG)
B. Venous duplex ultrasound
Which of the following is NOT a classic feature of metabolic syndrome?
A. Abdominal obesity
B. Hyperglycemia
C. Hyperkalemia
D. Hypertension
C. Hyperkalemia
Which ECG finding is most suggestive of acute pericarditis?
A. ST-segment elevation in all leads
B. ST-segment depression in inferior leads
C. Delta waves
D. Q waves in V1-V3
A. ST-segment elevation in all leads
A patient with known heart failure presents with worsening dyspnea and pulmonary congestion. Which medication is most appropriate for rapid symptomatic relief?
A. Beta-blockers
B. Loop diuretics
C. ACE inhibitors
D. Digoxin
B. Loop diuretics
Which of the following is the most important first step in managing a patient with suspected acute coronary syndrome (ACS)?
A. Order an echocardiogram
B. Administer IV fluids
C. Obtain an ECG
D. Give a beta-blocker
C. Obtain an ECG
Which condition is most likely to cause paradoxical splitting of the second heart sound (S2)?
A. Pulmonary stenosis
B. Aortic stenosis
C. Mitral regurgitation
D. Atrial fibrillation
B. Aortic stenosis
Which test is most useful for evaluating cardiac function in a patient with suspected congestive heart failure?
A. Pulmonary function test
B. Serum creatinine
C. B-type natriuretic peptide (BNP) level
D. Holter monitor
C. B-type natriuretic peptide (BNP) level
Which feature is most consistent with unstable angina?
A. Chest pain that occurs only during exertion
B. Chest pain relieved by rest or nitroglycerin
C. New-onset, severe chest pain at rest
D. Chest pain associated with ST-segment elevation
C. New-onset, severe chest pain at rest
Which condition is commonly associated with pulsus paradoxus?
A. Aortic stenosis
B. Cardiac tamponade
C. Mitral stenosis
D. Hypertrophic cardiomyopathy
B. Cardiac tamponade
Explanation:
Pulsus paradoxus is an exaggerated drop in systolic blood pressure (>10 mmHg) during inspiration and is commonly associated with cardiac tamponade.
• In cardiac tamponade, excessive pericardial fluid compresses the heart, limiting right ventricular filling.
During inspiration:
• Increased venous return to the right heart further compresses the left ventricle, reducing left ventricular output and causing a greater-than-normal drop in systolic BP.
• Pulsus paradoxus can also occur in severe asthma, COPD, and constrictive pericarditis, but cardiac tamponade is the most classic cause.
Why not the other options?
A. Aortic stenosis → Causes pulsus parvus et tardus (slow and weak carotid pulse), not pulsus paradoxus.
C. Mitral stenosis → Leads to left atrial enlargement and pulmonary congestion, but does not cause pulsus paradoxus.
D. Hypertrophic cardiomyopathy (HCM) → Associated with pulsus bisferiens (biphasic pulse) due to dynamic left ventricular outflow obstruction, not pulsus paradoxus.
Which heart valve is most commonly affected in infective endocarditis in intravenous drug users?
A. Aortic valve
B. Mitral valve
C. Pulmonary valve
D. Tricuspid valve
D. Tricuspid valve
A 40-year-old female presents with episodic headaches, palpitations, and hypertension. Which test is most appropriate to confirm pheochromocytoma?
A. Renal ultrasound
B. 24-hour urine metanephrines
C. Serum cortisol
D. ECG
B. 24-hour urine metanephrines
Which finding is most characteristic of hypertrophic cardiomyopathy?
A. Wide pulse pressure
B. Harsh systolic murmur that increases with Valsalva
C. Diastolic decrescendo murmur
D. Fixed split S2
B. Harsh systolic murmur that increases with Valsalva
Which condition is most commonly associated with mitral stenosis?
A. Systemic hypertension
B. Rheumatic heart disease
C. Aortic aneurysm
D. Atrial septal defect
B. Rheumatic heart disease
Which ECG finding is characteristic of Wolff-Parkinson-White syndrome?
A. Peaked T waves
B. ST-segment elevation in V1-V3
C. Delta waves
D. QT interval prolongation
C. Delta waves
A patient presents with exertional chest pain and a harsh systolic murmur at the right upper sternal border. Which is the most likely diagnosis?
A. Aortic stenosis
B. Mitral regurgitation
C. Tricuspid regurgitation
D. Atrial septal defect
A. Aortic stenosis
Which feature distinguishes stable angina from unstable angina?
A. Pain lasting longer than 30 minutes
B. Pain relieved by nitroglycerin and rest
C. Chest pain at rest
D. ST-segment elevation on ECG
B. Pain relieved by nitroglycerin and rest
Which condition is commonly associated with a “water hammer” pulse?
A. Aortic regurgitation
B. Mitral stenosis
C. Pulmonary hypertension
D. Tricuspid stenosis
A. Aortic regurgitation
Which of the following is an absolute contraindication to thrombolytic therapy in acute myocardial infarction?
A. History of stable angina
B. History of recent peptic ulcer disease
C. Prior intracranial hemorrhage
D. Mild hypertension
C. Prior intracranial hemorrhage
Which condition is characterized by an S4 heart sound?
A. Mitral stenosis
B. Aortic regurgitation
C. Left ventricular hypertrophy
D. Atrial fibrillation
C. Left ventricular hypertrophy
Which of the following medications reduces mortality in systolic heart failure?
A. Digoxin
B. Loop diuretics
C. Beta-blockers
D. Calcium channel blockers
C. Beta-blockers
Which murmur is best heard at the apex and has a “holosystolic” pattern?
A. Aortic stenosis
B. Mitral regurgitation
C. Atrial septal defect
D. Pulmonary stenosis
B. Mitral regurgitation
Which of the following is the primary purpose of diagnostic cardiac catheterization?
A. Therapeutic intervention
B. Hemodynamic assessment
C. Electrophysiological mapping
D. Myocardial biopsy
B. Hemodynamic assessment
What is the most common access site for left heart catheterization?
A. Radial artery
B. Femoral artery
C. Brachial artery
D. Subclavian artery
B. Femoral artery
Which imaging modality is typically used during coronary angiography to visualize coronary arteries?
A. Magnetic Resonance Imaging (MRI)
B. Computed Tomography (CT)
C. Fluoroscopy
D. Ultrasound
C. Fluoroscopy
Which of the following is a common indication for coronary angiography?
A. Evaluation of heart murmurs
B. Assessment of peripheral artery disease
C. Diagnosis of coronary artery disease
D. Screening for arrhythmias
C. Diagnosis of coronary artery disease
What is the primary risk associated with cardiac catheterization?
A. Infection
B. Stroke
C. Contrast-induced nephropathy
D. Radiation exposure
C. Contrast-induced nephropathy
Which of the following is a relative contraindication to cardiac catheterization?
A. Uncontrolled hypertension
B. Severe anemia
C. Active gastrointestinal bleeding
D. All of the above
D. All of the above
During right heart catheterization, which parameter is directly measured?
A. Left ventricular end-diastolic pressure
B. Pulmonary capillary wedge pressure
C. Coronary artery flow
D. Aortic pressure
B. Pulmonary capillary wedge pressure
Which complication is most commonly associated with the femoral artery access site?
A. Pneumothorax
B. Hematoma formation
C. Brachial plexus injury
D. Carotid artery dissection
B. Hematoma formation
What is the purpose of administering anticoagulants during cardiac catheterization?
A. To prevent contrast reactions
B. To reduce the risk of thrombus formation
C. To manage hypertension
D. To enhance image quality
B. To reduce the risk of thrombus formation
Which of the following is a potential allergic reaction during coronary angiography?
A. Bradycardia
B. Urticaria
C. Hypertension
D. Hyperglycemia
B. Urticaria
What does Fractional Flow Reserve (FFR) assess during coronary angiography?
A. Electrical activity of the heart
B. Myocardial viability
C. Physiological significance of coronary stenosis
D. Ventricular function
Physiological significance of coronary stenosis
Which technique uses sound waves to visualize the interior of coronary arteries?
A. Optical Coherence Tomography (OCT)
B. Intravascular Ultrasound (IVUS)
C. Positron Emission Tomography (PET)
D. Single-Photon Emission Computed Tomography (SPECT)
B. Intravascular Ultrasound (IVUS)
Which of the following is an advantage of the radial artery approach over the femoral artery approach in cardiac catheterization?
A. Lower risk of bleeding complications
B. Shorter procedure time
C. Reduced need for contrast media
D. Improved image quality
A. Lower risk of bleeding complications
What is the primary purpose of ventriculography performed during cardiac catheterization?
A. To assess coronary artery patency
B. To evaluate left ventricular function
C. To measure pulmonary pressures
D. To visualize aortic anatomy
B. To evaluate left ventricular function
Which medication is commonly used to prevent vessel spasm during radial artery catheterization?
A. Nitroglycerin
B. Atropine
C. Lidocaine
D. Heparin
A. Nitroglycerin
Which of the following is a common post-procedure complication of cardiac catheterization?
A. Deep vein thrombosis
B. Acute renal failure
C. Pericarditis
D. Myocarditis
B. Acute renal failure
What is the recommended management for a patient with a small hematoma at the catheter insertion site?
A. Surgical intervention
B. Compression and observation
C. Thrombolytic therapy
D. Antibiotic administration
B. Compression and observation
Which factor increases the risk of contrast-induced nephropathy?
A. Young age
B. Dehydration
C. Low contrast volume
D. Hyperthyroidism
B. Dehydration
Which of the following is a benefit of using Optical Coherence Tomography (OCT) in coronary imaging?
A. Deeper tissue penetration
B. Higher resolution imaging
C. Lower cost compared to IVUS
D. Reduced need for contrast agents
B. Higher resolution imaging
During cardiac catheterization, what does a significant pressure gradient across the aortic valve indicate?
A. Aortic regurgitation
B. Aortic stenosis
C. Mitral stenosis
D. Pulmonary hypertension
B. Aortic stenosis
Which patient population is at increased risk for vascular complications during cardiac catheterization?
A. Patients with obesity
B. Patients with peripheral artery disease
C. Patients with diabetes mellitus
D. All of the above
D. All of the above
What is the role of heparin during coronary angiography?
A. To dissolve existing clots
B. To prevent new clot formation
C. To enhance contrast agent visibility
D. To reduce vascular spasm
B. To prevent new clot formation
Explanation:
Heparin is used during coronary angiography to prevent thrombus formation within the coronary arteries and catheters.
Mechanism of Action:
• Heparin enhances the activity of antithrombin III (ATIII), which inactivates thrombin (Factor IIa) and Factor Xa, preventing the formation of new clots.
• It does not actively dissolve existing thrombi but helps prevent clot propagation.
• Why is heparin needed in coronary angiography?
• The procedure involves catheter manipulation inside arteries, which can trigger platelet aggregation and clot formation.
• Preventing thrombus formation is crucial to reduce the risk of myocardial infarction (MI) or stroke during the procedure.
Why not the other options?
A. To dissolve existing clots → Incorrect. Heparin prevents new clot formation but does not lyse existing thrombi. Thrombolytic agents (e.g., alteplase, tenecteplase) are used for clot dissolution.
C. To enhance contrast agent visibility → Incorrect. Contrast visibility is dependent on radiographic density, not heparin.
D. To reduce vascular spasm → Incorrect. Nitrates (e.g., nitroglycerin) or calcium channel blockers are used to relieve vascular spasm, not heparin.
Which finding during coronary angiography suggests significant coronary artery disease?
A. 30% luminal narrowing
B. 50% luminal narrowing
C. 70% luminal narrowing
D. 90% luminal narrowing
C. 70% luminal narrowing
Which of the following is the best strategy to prevent contrast-induced nephropathy in high-risk patients undergoing cardiac catheterization?
A. Pre-procedure hydration with intravenous fluids
B. Administration of diuretics before the procedure
C. Use of high-osmolar contrast agents
D. Routine use of nephrotoxic medications
B. Administration of diuretics before the procedure
Which of the following is a contraindication to the use of iodinated contrast in coronary angiography?
A. History of stroke
B. Known contrast allergy
C. Hypertension
D. Chronic obstructive pulmonary disease (COPD)
B. Known contrast allergy
Which of the following findings on coronary angiography is considered severe coronary artery disease?
A. <30% stenosis
B. 50% stenosis of any coronary artery
C. 70% stenosis of a major epicardial artery
D. 90% stenosis of a small branch artery
C. 70% stenosis of a major epicardial artery
Which coronary artery is most commonly involved in an ST-elevation myocardial infarction (STEMI) affecting the anterior wall of the heart?
A. Right coronary artery (RCA)
B. Left circumflex artery (LCX)
C. Left anterior descending artery (LAD)
D. Posterior descending artery (PDA)
C. Left anterior descending artery (LAD)
Which of the following is a major advantage of fractional flow reserve (FFR) in coronary assessment?
A. It provides anatomical visualization of stenotic lesions
B. It determines the hemodynamic significance of coronary stenoses
C. It replaces the need for coronary angiography
D. It eliminates the need for percutaneous coronary intervention (PCI)
B. It determines the hemodynamic significance of coronary stenoses
Which artery supplies the inferior wall of the heart in most individuals?
A. Left anterior descending artery (LAD)
B. Left circumflex artery (LCX)
C. Right coronary artery (RCA)
D. Diagonal artery
C. Right coronary artery (RCA)
Which imaging technique provides the highest resolution for assessing coronary plaque morphology?
A. Intravascular Ultrasound (IVUS)
B. Optical Coherence Tomography (OCT)
C. Magnetic Resonance Angiography (MRA)
D. Computed Tomography Angiography (CTA)
B. Optical Coherence Tomography (OCT)
Which complication of cardiac catheterization is most likely if a patient develops sudden hypotension, tachycardia, and pericardial effusion?
A. Acute myocardial infarction
B. Coronary artery dissection
C. Cardiac tamponade
D. Acute kidney injury
C. Cardiac tamponade
Which of the following is an indication for urgent coronary angiography?
A. Stable angina with mild symptoms
B. Low-risk chest pain in an outpatient setting
C. ST-elevation myocardial infarction (STEMI)
D. Mild coronary artery disease on prior stress test
C. ST-elevation myocardial infarction (STEMI)
What is the primary mechanism by which contrast agents used in cardiac catheterization can cause kidney injury?
A. Direct nephrotoxicity
B. Induction of renal artery thrombosis
C. Volume overload
D. Increased glomerular filtration rate
A. Direct nephrotoxicity
Which physical sign is most indicative of severe aortic stenosis?
A. Loud S1
B. Soft S2
C. Loud P2
D. Soft S1
B. Soft S2
A bounding carotid pulse is most commonly associated with which condition?
A. Aortic stenosis
B. Aortic regurgitation
C. Mitral stenosis
D. Pulmonary hypertension
B. Aortic regurgitation
Explanation:
A bounding carotid pulse (also called Corrigan’s pulse or water hammer pulse) is most commonly associated with aortic regurgitation (AR).
• In AR, blood leaks back into the left ventricle during diastole, causing:
• Increased stroke volume → Stronger systolic pulse.
• Rapid diastolic runoff → Widened pulse pressure and bounding pulses.
Key pulse findings in AR:
• Water hammer pulse (Corrigan’s pulse): Rapid upstroke and quick collapse.
• Quincke’s sign: Nail bed capillary pulsations.
• Traube’s sign: “Pistol-shot” sounds over femoral arteries.
Why not the other options?
A. Aortic stenosis → Causes pulsus parvus et tardus (weak and delayed carotid pulse), not bounding pulses.
C. Mitral stenosis → Does not affect pulse amplitude; instead, it causes left atrial enlargement and pulmonary congestion.
D. Pulmonary hypertension → Can cause accentuated P2 heart sound and right heart strain, but it does not lead to bounding pulses.
The presence of a third heart sound (S3) is most commonly associated with:
A. Atrial septal defect
B. Heart failure
C. Hypertrophic cardiomyopathy
D. Pericarditis
B. Heart failure
Which maneuver increases the intensity of hypertrophic cardiomyopathy murmurs?
A. Squatting
B. Handgrip
C. Standing
D. Leg elevation
C. Standing
A pericardial friction rub is best heard:
A. At the apex in the left lateral decubitus position
B. Along the left sternal border with the patient leaning forward
C. Over the right second intercostal space
D. At the base with the patient supine
B. Along the left sternal border with the patient leaning forward
Pulsus paradoxus is defined as:
A. A decrease in systolic blood pressure >10 mmHg during inspiration
B. An increase in systolic blood pressure >10 mmHg during inspiration
C. A decrease in diastolic blood pressure >10 mmHg during expiration
D. An increase in diastolic blood pressure >10 mmHg during expiration
A. A decrease in systolic blood pressure >10 mmHg during inspiration
The hepatojugular reflux is a sign of:
A. Left ventricular hypertrophy
B. Right ventricular failure
C. Pulmonary embolism
D. Aortic dissection
B. Right ventricular failure
The presence of a fourth heart sound (S4) is most commonly associated with:
A. Atrial fibrillation
B. Ventricular hypertrophy
C. Mitral regurgitation
D. Patent ductus arteriosus
B. Ventricular hypertrophy
Which physical finding is characteristic of constrictive pericarditis?
A. Kussmaul’s sign
B. Pulsus alternans
C. Corrigan’s pulse
D. Austin Flint murmur
A. Kussmaul’s sign
A continuous “machinery” murmur is indicative of:
A. Ventricular septal defect
B. Atrial septal defect
C. Patent ductus arteriosus
D. Mitral regurgitation
C. Patent ductus arteriosus
The “a” wave in the jugular venous pulse corresponds to:
A. Atrial contraction
B. Ventricular contraction
C. Atrial relaxation
D. Ventricular filling
A. Atrial contraction
Which condition is associated with a “parvus et tardus” carotid pulse?
A. Aortic stenosis
B. Aortic regurgitation
C. Mitral stenosis
D. Tricuspid regurgitation
A. Aortic stenosis
A wide pulse pressure is commonly seen in:
A. Aortic stenosis
B. Aortic regurgitation
C. Mitral stenosis
D. Pulmonary hypertension
B. Aortic regurgitation
The presence of Osler’s nodes is associated with:
A. Acute pericarditis
B. Bacterial endocarditis
C. Aortic dissection
D. Myocardial infarction
B. Bacterial endocarditis
Janeway lesions are painless erythematous macules found on the:
A. Face
B. Palm and soles
C. Neck
D. Back
B. Palm and soles
Which physical examination finding is most indicative of severe mitral stenosis?
A. Diastolic murmur with an opening snap
B. Holosystolic murmur at the apex
C. Diastolic murmur over the aortic area
D. Harsh systolic murmur over the carotid
A. Diastolic murmur with an opening snap
Which condition is most commonly associated with a “pistol-shot” femoral pulse?
A. Aortic stenosis
B. Aortic regurgitation
C. Mitral stenosis
D. Tricuspid stenosis
B. Aortic regurgitation
A harsh holosystolic murmur at the lower left sternal border suggests:
A. Mitral stenosis
B. Aortic stenosis
C. Ventricular septal defect
D. Atrial septal defect
C. Ventricular septal defect
A patient presents with syncope. ECG shows sinus rhythm with intermittent dropped QRS complexes without PR prolongation. What is the most likely diagnosis?
A) First-degree AV block
B) Second-degree AV block Mobitz Type I (Wenckebach)
C) Second-degree AV block Mobitz Type II
D) Third-degree AV block
Answer: C (Mobitz Type II has dropped beats with a fixed PR interval, indicating a problem below the AV node.)
A 65-year-old with exertional dyspnea has ECG showing left axis deviation, deep S waves in V1-V2, and broad notched R waves in V5-V6. What is the most likely diagnosis?
A) Left bundle branch block
B) Right bundle branch block
C) Left ventricular hypertrophy
D) Ventricular tachycardia
A (LBBB criteria include broad R in V5-V6, deep S in V1, and left axis deviation.)
In a patient with hyperkalemia, which ECG change is most predictive of impending cardiac arrest?
A) Peaked T waves
B) Widened QRS complex
C) PR prolongation
D) Shortened QT interval
Answer: B (A widening QRS suggests impending ventricular fibrillation due to conduction block.)
A 50-year-old male presents with chest pain. ECG shows ST elevation in V2-V4 with deep Q waves. Which artery is likely occluded?
A) Right coronary artery (RCA)
B) Left circumflex artery (LCx)
C) Left anterior descending artery (LAD)
D) Posterior descending artery (PDA)
Answer: C (Anterior STEMI due to LAD occlusion causes ST elevation in V1-V4.)
A patient with syncope has an ECG with broad QRS complexes (>120 ms), rightward axis, and an RSR’ pattern in V1. What is the likely cause?
A) Right bundle branch block (RBBB)
B) Left bundle branch block (LBBB)
C) Ventricular tachycardia
D) Brugada syndrome
Answer: A (RBBB shows a characteristic RSR’ in V1 and a wide QRS.)
Which ECG abnormality is most characteristic of acute pericarditis?
A) ST-segment elevation in multiple leads without reciprocal changes
B) ST-segment elevation only in inferior leads
C) ST-segment depression in V1-V3
D) Peaked T waves
Answer: A (Pericarditis classically causes diffuse ST elevation and PR depression.)
A patient has an ECG with tachycardia, QRS duration of 180 ms, and AV dissociation. What is the diagnosis?
A) Atrial fibrillation with aberrancy
B) Ventricular tachycardia
C) Supraventricular tachycardia
D) Torsades de pointes
Answer: B (Wide-complex tachycardia + AV dissociation strongly suggests VT.)
A 40-year-old male with palpitations has a short PR interval and delta wave. What is the diagnosis?
A) Atrial fibrillation
B) Ventricular pre-excitation (Wolff-Parkinson-White syndrome)
C) First-degree AV block
D) Torsades de pointes
Answer: B (WPW syndrome has a short PR interval + delta wave due to an accessory pathway.)
Which finding suggests a posterior MI?
A) ST elevation in leads V1-V3
B) ST depression in V1-V3
C) Tall, peaked P waves
D) ST elevation in lead III only
Answer: B (ST depression in V1-V3 is a mirror image of posterior STEMI.)
In Torsades de Pointes, which electrolyte abnormality is most likely responsible?
A) Hyperkalemia
B) Hypocalcemia
C) Hypomagnesemia
D) Hypernatremia
Answer: C (Hypomagnesemia prolongs the QT interval, predisposing to Torsades.)
A patient on amiodarone develops a markedly prolonged QT interval. Which arrhythmia is most concerning?
A) Ventricular fibrillation
B) Sinus tachycardia
C) Torsades de Pointes
D) AV dissociation
Answer: C (Amiodarone can cause QT prolongation, leading to Torsades.)
A tall, thin 30-year-old male has deep, narrow Q waves in V1-V3 without chest pain. What is the likely cause?
A) Prior anteroseptal MI
B) Hypertrophic cardiomyopathy
C) Arrhythmogenic right ventricular cardiomyopathy (ARVC)
D) Normal variant
Answer: D (Young, thin individuals often have benign Q waves in V1-V3 due to heart position.)
Which ECG sign is most specific for hypothermia?
A) Sinus bradycardia
B) Osborne waves (J waves)
C) Prolonged PR interval
D) ST-segment depression
Answer: B (Osborne waves are classic for hypothermia.)
A 68-year-old hypertensive patient has LVH on ECG with inverted T waves in V5-V6. What is this called?
A) LV strain pattern
B) Hyperkalemia
C) Left atrial enlargement
D) Inferior ischemia
Answer: A (LV strain pattern = LVH + inverted T waves in lateral leads.)
A 55-year-old male presents with chest pain. ECG shows ST elevation in aVR and V1, with diffuse ST depression elsewhere. What is the likely diagnosis?
A) STEMI
B) Left main coronary artery occlusion
C) Posterior MI
D) Benign early repolarization
Answer: B (ST elevation in aVR + widespread ST depression suggests left main occlusion.)
A patient with PEA arrest has a heart rate of 40 bpm, dissociated P waves, and a narrow QRS. What rhythm is likely?
A) Junctional escape rhythm
B) Complete heart block
C) Ventricular escape rhythm
D) Atrial fibrillation
Answer: B (Complete heart block has a slow escape rhythm + dissociated P waves.)
A patient presents with syncope. ECG shows a wide QRS tachycardia at 180 bpm, no P waves, and fusion beats. What is the most likely diagnosis?
A) Supraventricular tachycardia (SVT) with aberrancy
B) Ventricular tachycardia (VT)
C) Atrial fibrillation with rapid ventricular response
D) Wolff-Parkinson-White syndrome
Answer: B (Wide QRS + fusion beats = VT until proven otherwise.)
ST elevation in V1-V2, with a RBBB pattern and T wave inversions, is characteristic of:
A) Brugada syndrome
B) Anterior STEMI
C) Wellens syndrome
D) Early repolarization
Answer: A (Brugada syndrome = ST elevation in V1-V2 + RBBB-like pattern.)
Explanation:
Brugada syndrome is an inherited cardiac channelopathy that increases the risk of ventricular arrhythmias and sudden cardiac death (SCD).
Characteristic ECG findings in Brugada syndrome:
• ST-segment elevation in V1-V2 (often with a “coved” or “saddleback” morphology).
• Right bundle branch block (RBBB) pattern (incomplete or complete).
• T-wave inversions in V1-V2.
• Increased risk of polymorphic ventricular tachycardia (VT) or ventricular fibrillation (VF).
Clinical Features:
• Typically seen in young males.
• Symptoms include syncope or nocturnal sudden cardiac death.
• Can be unmasked by fever, sodium channel blockers (e.g., flecainide), alcohol, or vagal stimulation.
Why not the other options?
B) Anterior STEMI → Also causes ST elevation in V1-V2, but:
• Typically involves more leads (V1-V4) due to LAD occlusion.
• No characteristic RBBB pattern.
• More often presents with chest pain, diaphoresis, and hemodynamic instability.
C) Wellens syndrome → Marked by:
• Deeply inverted or biphasic T waves in V2-V3, not ST elevation.
• Associated with critical proximal LAD stenosis, but no RBBB pattern.
D) Early repolarization → Causes ST elevation, but:
• More common in young, healthy individuals.
• No RBBB or T-wave inversions in V1-V2.
• ST elevation has a “fishhook” appearance in leads V4-V6.
A 65-year-old with syncope and a bifascicular block has intermittent complete AV block on ECG. What is the best management?
A) Observation
B) IV atropine
C) Permanent pacemaker
D) Beta-blockers
Answer: C (Bifascicular block + AV block = high risk of progression to complete heart block → pacemaker.)
ST elevation in lead III > lead II suggests occlusion of which artery?
A) Right coronary artery (RCA)
B) Left anterior descending (LAD)
C) Left circumflex artery (LCx)
D) Posterior descending artery (PDA)
Answer: A (Inferior MI with ST elevation in III > II suggests RCA occlusion.)
A young female presents with palpitations. ECG shows narrow QRS tachycardia (HR 180 bpm) with retrograde P waves. Diagnosis?
A) AVNRT
B) Atrial flutter
C) Sinus tachycardia
D) Multifocal atrial tachycardia
Answer: A (AVNRT has a regular, narrow QRS tachycardia with retrograde P waves.)
ST elevation in V4R is most suggestive of:
A) Anterior STEMI
B) Right ventricular infarction
C) Posterior MI
D) Brugada syndrome
Answer: B (ST elevation in V4R = RV infarction → Avoid nitrates.)
A 35-year-old with palpitations has a short PR interval and delta wave. What is the best initial treatment?
A) IV adenosine
B) Beta-blockers
C) Catheter ablation
D) Procainamide
Answer: D (WPW syndrome → Avoid AV nodal blockers (adenosine, BBs) due to risk of VF.)
A patient with atrial fibrillation and Wolff-Parkinson-White syndrome is at highest risk of developing:
A) Sinus bradycardia
B) Torsades de Pointes
C) Ventricular fibrillation
D) Complete heart block
Answer: C (WPW + Afib → Can degenerate into VF if AV blockers are given.)
A 60-year-old male with chronic alcoholism has an ECG with prolonged QT interval and polymorphic ventricular tachycardia. Which electrolyte is most likely abnormal?
A) Potassium
B) Magnesium
C) Sodium
D) Calcium
Answer: B (Hypomagnesemia → Torsades de Pointes, common in alcoholics.)
A patient with hypertrophic cardiomyopathy (HCM) is most likely to show which ECG feature?
A) Left axis deviation
B) Giant T-wave inversions in anterior leads
C) Low voltage QRS
D) Delta wave
Answer: B (HCM shows deep T-wave inversions in V2-V4 due to septal hypertrophy.)
A pacemaker ECG shows no P waves, a regular, slow rhythm at 30 bpm, and a wide QRS. What is the pacemaker failure?
A) Failure to sense
B) Failure to capture
C) Oversensing
D) Lead dislodgement
Answer: B (Failure to capture = pacemaker fires, but no QRS is generated.)
ECG of a patient with hypercalcemia will likely show:
A) Short QT interval
B) Peaked T waves
C) Prolonged QT interval
D) ST elevation
Answer: A (Hypercalcemia = Shortened QT due to faster repolarization.)
In a patient with atrial flutter, the typical atrial rate is:
A) 100-150 bpm
B) 150-250 bpm
C) 250-350 bpm
D) 400-500 bpm
Answer: C (Atrial flutter typically has an atrial rate of 250-350 bpm.)
Which ECG change is most consistent with hypothermia?
A) Peaked T waves
B) U waves
C) Osborne (J) waves
D) ST-segment depression
Answer: C (Osborne waves are classic for hypothermia.)
A 75-year-old diabetic presents with syncope. ECG shows sinus bradycardia, PR interval > 200 ms, and no dropped beats. What is the most likely cause?
A) First-degree AV block
B) Second-degree AV block
C) Sinus node dysfunction
D) Third-degree AV block
Answer: A (First-degree AV block = PR > 200 ms but no dropped beats.)
Which ECG feature is most suggestive of posterior MI?
A) ST elevation in V1-V3
B) ST depression in V1-V3
C) Peaked P waves
D) ST elevation in aVR
Answer: B (ST depression in V1-V3 suggests posterior MI, a mirror image of ST elevation.)
A patient with massive pulmonary embolism is most likely to have which ECG change?
A) S1Q3T3 pattern
B) ST elevation in V2-V4
C) Delta waves
D) Shortened PR interval
Answer: A (S1Q3T3 pattern = Deep S in I, Q wave in III, T-wave inversion in III.)
A 63-year-old with COPD has multifocal P wave morphologies and an irregular rhythm. Diagnosis?
A) Atrial fibrillation
B) Atrial flutter
C) Multifocal atrial tachycardia (MAT)
D) Junctional rhythm
Answer: C (MAT is common in COPD and shows at least 3 different P-wave morphologies.)
An 80-year-old presents with syncope. ECG shows irregular rhythm, no P waves, and narrow QRS complexes. What is the diagnosis?
A) Atrial fibrillation
B) Atrial flutter
C) Junctional rhythm
D) Sinus node dysfunction
Answer: A (Atrial fibrillation = Irregularly irregular rhythm, absent P waves.)
A patient with dilated cardiomyopathy develops ventricular tachycardia. Which ECG feature suggests a poor prognosis?
A) Wide QRS
B) T-wave inversion
C) QRS fragmentation
D) Short QT interval
Answer: C (QRS fragmentation = scar-related VT, poor prognosis.)
Which echocardiographic technique is most sensitive for detecting left atrial thrombus?
A) Transthoracic echocardiography (TTE)
B) Stress echocardiography
C) Transesophageal echocardiography (TEE)
D) Contrast echocardiography
Answer: C (TEE has superior resolution of left atrial appendage thrombi.)
A patient with exertional dyspnea undergoes stress echocardiography. New hypokinesis in the anterior wall is noted. What is the likely coronary artery involvement?
A) Left anterior descending (LAD)
B) Right coronary artery (RCA)
C) Left circumflex artery (LCx)
D) Posterior descending artery (PDA)
Answer: A (LAD occlusion → anterior wall hypokinesis.)
Which echocardiographic finding is most specific for cardiac tamponade?
A) Left ventricular hypertrophy
B) Right atrial collapse during systole
C) Pericardial effusion
D) Left atrial enlargement
Answer: B (Right atrial collapse during systole is an early sign of tamponade.)
Which condition can be diagnosed only using Doppler echocardiography?
A) Left atrial thrombus
B) Pulmonary hypertension
C) Pericardial effusion
D) Aortic aneurysm
Answer: B (Doppler echocardiography estimates pulmonary pressures using tricuspid regurgitation velocity.)
In HCM, which echocardiographic feature is most characteristic?
A) Concentric left ventricular hypertrophy
B) Asymmetric septal hypertrophy with systolic anterior motion of the mitral valve
C) Global hypokinesis
D) Right ventricular dilatation
Answer: B (HCM = Asymmetric septal hypertrophy + systolic anterior motion of MV.)
Which parameter is used to assess diastolic dysfunction on echocardiography?
A) E/A ratio
B) LV ejection fraction
C) Left atrial size
D) Right ventricular function
Answer: A (E/A ratio (early-to-late ventricular filling velocity) reflects diastolic dysfunction.)
Which echocardiographic technique is most useful for assessing valvular regurgitation severity?
A) M-mode
B) 2D imaging
C) Doppler echocardiography
D) Contrast echocardiography
Answer: C (Doppler echocardiography measures regurgitant jet velocity and flow.)
A bubble contrast study is performed. The presence of bubbles in the left atrium within three cardiac cycles suggests:
A) Aortic stenosis
B) Ventricular septal defect
C) Patent foramen ovale (PFO)
D) Pulmonary embolism
Answer: C (PFO allows bubbles to pass from the right atrium to the left atrium.)
Which Doppler parameter is used to estimate pulmonary artery systolic pressure?
A) Mitral E/A ratio
B) Tricuspid regurgitant velocity
C) Aortic valve velocity
D) Left ventricular outflow tract velocity
Answer: B (Tricuspid regurgitant velocity helps estimate pulmonary artery pressures.)
Which nuclear imaging modality is best for evaluating myocardial viability?
A) 99mTc-sestamibi SPECT
B) 18F-FDG PET
C) Stress echocardiography
D) Coronary CTA
Answer: B (FDG PET assesses myocardial viability by identifying metabolically active but dysfunctional myocardium.)
What is the most common radioisotope used in nuclear stress testing?
A) Thallium-201
B) Technetium-99m
C) Iodine-123
D) Gallium-67
Answer: B (Technetium-99m is commonly used in SPECT myocardial perfusion imaging.)
A patient undergoes a dipyridamole stress test. What is the mechanism of action of dipyridamole?
A) Direct coronary vasoconstriction
B) Beta-adrenergic stimulation
C) Coronary steal phenomenon
D) Increased myocardial contractility
Answer: C (Dipyridamole induces coronary steal, revealing ischemic territories.)
Which cardiac imaging modality is the gold standard for assessing myocardial fibrosis?
A) Echocardiography
B) SPECT nuclear imaging
C) Cardiac MRI with late gadolinium enhancement
D) Coronary angiography
Answer: C (Cardiac MRI with late gadolinium enhancement detects myocardial fibrosis.)
In aortic dissection, which imaging modality is most accurate?
A) Transthoracic echocardiography
B) Coronary angiography
C) Cardiac CT angiography
D) Nuclear perfusion imaging
Answer: C (CT angiography is the preferred test for aortic dissection.)
Which finding on cardiac MRI suggests amyloidosis?
A) Subendocardial late gadolinium enhancement
B) Patchy fibrosis
C) Mid-wall late gadolinium enhancement
D) Global transmural infarction
Answer: A (Amyloidosis → Subendocardial late gadolinium enhancement.)
Explanation:
Cardiac amyloidosis is a restrictive cardiomyopathy caused by amyloid deposition in the myocardium, leading to diastolic dysfunction, heart failure, and arrhythmias.
Cardiac MRI Findings in Amyloidosis:
• Subendocardial late gadolinium enhancement (LGE) → Classic finding due to amyloid infiltration in the subendocardial layer.
• Diffuse/global LGE (not localized to coronary artery territories).
• Increased extracellular volume (ECV) on T1 mapping due to amyloid deposits.
• Abnormal gadolinium washout (difficulty nulling the myocardium on inversion recovery imaging).
Why not the other options?
B) Patchy fibrosis → More characteristic of sarcoidosis, which causes non-coronary distribution fibrosis.
C) Mid-wall late gadolinium enhancement → Seen in non-ischemic cardiomyopathies (e.g., dilated cardiomyopathy, myocarditis, hypertrophic cardiomyopathy), not amyloidosis.
D) Global transmural infarction → Suggests severe multi-vessel coronary artery disease (CAD) or prior infarction, not amyloidosis.
A coronary artery calcium (CAC) score of 0 on CT suggests:
A) No significant coronary artery disease
B) High risk of MI
C) Coronary vasospasm
D) Need for urgent coronary angiography
Answer: A (CAC = 0 means low risk of obstructive CAD.)
Explanation:
The coronary artery calcium (CAC) score is measured using non-contrast cardiac CT and reflects the burden of coronary atherosclerosis.
CAC Score Interpretation:
• 0 → No detectable coronary calcification → Very low likelihood of obstructive CAD (<1%).
• 1-99 → Mild atherosclerosis, low-to-moderate risk.
• 100-399 → Moderate atherosclerosis, higher risk.
• ≥400 → Extensive atherosclerosis, high risk of obstructive CAD.
Clinical Significance of a CAC Score of 0:
• Strongly predicts a very low 10-year risk of major adverse cardiac events (MACE).
• Commonly used to defer statin therapy in low-risk patients.
• Does not rule out non-calcified (soft) plaque, but obstructive disease is highly unlikely.
Why not the other options?
B) High risk of MI → Incorrect, since a CAC score of 0 suggests a very low risk of myocardial infarction (MI).
C) Coronary vasospasm → Incorrect, because CAC scoring detects atherosclerosis, not vasospasm, which is best evaluated with provocative testing.
D) Need for urgent coronary angiography → Incorrect, as a CAC score of 0 indicates no significant plaque burden, so invasive angiography is not necessary.
Which finding on cardiac CT suggests constrictive pericarditis?
A) Myocardial fibrosis
B) Pericardial thickening with calcifications
C) Right atrial enlargement
D) Left ventricular thrombus
Answer: B (Pericardial thickening + calcifications = constrictive pericarditis.)
Which combination of imaging is best for assessing cardiac sarcoidosis?
A) SPECT and echocardiography
B) PET and cardiac MRI
C) Coronary CT and nuclear imaging
D) TEE and stress echocardiography
Answer: B (PET detects inflammation, MRI detects fibrosis in sarcoidosis.)
Which modality is most sensitive for detecting left atrial appendage thrombi before cardioversion?
A) TTE
B) TEE
C) Cardiac MRI
D) Coronary CT
Answer: B (TEE is the gold standard for LAA thrombi.)
Which echocardiographic Doppler parameter best differentiates restrictive cardiomyopathy from constrictive pericarditis?
A) Mitral inflow E/A ratio
B) Respiratory variation in mitral inflow velocity
C) Isovolumic relaxation time
D) Left atrial volume index
Answer: B (Constrictive pericarditis shows exaggerated respiratory variation in mitral inflow, unlike restrictive cardiomyopathy.)
Which echocardiographic finding is most suggestive of severe aortic regurgitation?
A) Pressure half-time <200 ms
B) E/A ratio >1.5
C) Pulmonary vein systolic blunting
D) LVOT velocity >3 m/s
Answer: A (Pressure half-time <200 ms suggests severe AR due to rapid pressure equalization.)
In prosthetic valve dysfunction, which echocardiographic modality is most useful?
A) Transthoracic echocardiography (TTE)
B) Transesophageal echocardiography (TEE)
C) Doppler tissue imaging
D) 3D echocardiography
Answer: B (TEE is superior for prosthetic valve thrombosis, pannus formation, and paravalvular leaks.)
Myocardial strain imaging (speckle-tracking echocardiography) is most useful for:
A) Evaluating diastolic function
B) Detecting subclinical LV dysfunction
C) Measuring pulmonary artery pressure
D) Assessing RV systolic function
Answer: B (Global longitudinal strain (GLS) detects early LV dysfunction, e.g., in chemotherapy cardiotoxicity.)
Which echocardiographic finding is most specific for cardiac amyloidosis?
A) Increased LV wall thickness
B) Restrictive filling pattern
C) Apical sparing on longitudinal strain
D) Pericardial effusion
Answer: C (Apical sparing on strain imaging is highly specific for cardiac amyloidosis.)
Which contrast agent is used in echocardiography to assess myocardial perfusion?
A) Agitated saline
B) Perfluorocarbon microspheres
C) Definity (perflutren lipid microspheres)
D) Technetium-99m
Answer: C (Definity enhances myocardial perfusion imaging in contrast echocardiography.)
A post-cardiac transplant patient develops heart failure. What echocardiographic finding suggests allograft rejection?
A) Increased mitral inflow E/A ratio
B) Diastolic dysfunction with preserved ejection fraction
C) Reduced tissue Doppler e’ velocity
D) Increased LV mass
Answer: C (Reduced e’ velocity suggests graft rejection due to myocardial stiffness.)
In severe mitral stenosis, which echocardiographic parameter best predicts symptoms?
A) Mitral valve area
B) Mean transmitral gradient
C) Pulmonary artery systolic pressure
D) Ejection fraction
Answer: C (Pulmonary hypertension correlates best with symptom severity in mitral stenosis.)
In ischemic cardiomyopathy, which echocardiographic sign suggests myocardial hibernation rather than infarction?
A) Fixed wall motion abnormality
B) Reduced myocardial strain
C) Increased contractile reserve with dobutamine
D) Diastolic dysfunction
Answer: C (Dobutamine stress echocardiography reveals contractile reserve in hibernating myocardium.)
Which echocardiographic feature suggests chronic pulmonary embolism rather than acute PE?
A) Right ventricular dilatation
B) McConnell’s sign
C) Tricuspid regurgitant velocity >3.4 m/s
D) Increased RV wall thickness (>5 mm)
Answer: D (RV hypertrophy suggests chronic PE due to long-standing pressure overload.)
Which nuclear imaging finding is characteristic of cardiac sarcoidosis?
A) Diffuse myocardial FDG uptake
B) Patchy focal FDG uptake
C) Fixed perfusion defect
D) Homogeneous myocardial perfusion
Answer: B (Patchy FDG uptake = inflammatory activity in sarcoidosis.)
A false-positive nuclear stress test is most likely in which condition?
A) Diabetes mellitus
B) Left bundle branch block
C) Anemia
D) Chronic kidney disease
Answer: B (LBBB may cause false-positive perfusion defects in the septum.)
In arrhythmogenic right ventricular cardiomyopathy (ARVC), which MRI finding is most characteristic?
A) Subepicardial late gadolinium enhancement
B) RV outflow tract aneurysm
C) Transmural infarction
D) Global LV dysfunction
Answer: B (RV outflow tract aneurysm + fibrofatty infiltration = ARVC.)
In hypertrophic cardiomyopathy, late gadolinium enhancement (LGE) on MRI indicates:
A) Increased LV mass
B) Myocardial fibrosis
C) Diastolic dysfunction
D) High-output heart failure
Answer: B (LGE = Myocardial fibrosis, a marker for sudden cardiac death in HCM.)
A patient with chest pain undergoes stress myocardial perfusion imaging. Reversible ischemia is seen in the inferolateral wall. What is the likely coronary lesion?
A) Left anterior descending artery
B) Right coronary artery
C) Left circumflex artery
D) Ramus intermedius
Answer: C (LCx supplies inferolateral myocardium.)
Which imaging modality is best for assessing prosthetic valve endocarditis?
A) Transthoracic echocardiography
B) Transesophageal echocardiography
C) Nuclear SPECT imaging
D) Cardiac MRI
Answer: B (TEE is superior for detecting prosthetic valve endocarditis.)
A patient with known bicuspid aortic valve is being monitored for complications. Which echocardiographic finding is most commonly associated with this condition?
A) Aortic dissection
B) Left ventricular noncompaction
C) Aortic root dilatation
D) Rheumatic mitral stenosis
Answer: C (Aortic root dilatation is common in bicuspid aortic valve due to associated connective tissue abnormalities.)
In stress echocardiography, a new regional wall motion abnormality that persists during recovery most likely indicates:
A) Coronary vasospasm
B) Multivessel coronary artery disease
C) Myocardial stunning
D) Normal response to stress
Answer: C (Stunning = Prolonged post-ischemic dysfunction despite restored blood flow.)
Which echocardiographic feature best differentiates restrictive cardiomyopathy from constrictive pericarditis?
A) Left atrial size
B) Septal bounce
C) E/A ratio
D) Pulmonary artery pressure
Answer: B (Septal bounce is seen in constrictive pericarditis due to pericardial restraint.)
In Takotsubo cardiomyopathy, which echocardiographic pattern is characteristic?
A) Mid-LV hyperkinesis with apical akinesis
B) Global hypokinesis
C) Septal hypertrophy with systolic anterior motion of mitral valve
D) Right ventricular dilation with McConnell’s sign
Answer: A (Apical ballooning with basal hyperkinesis = Takotsubo cardiomyopathy.)
Which Doppler echocardiographic finding is most specific for severe mitral stenosis?
A) Mitral valve area <1.5 cm²
B) Mean diastolic pressure gradient >10 mmHg
C) Pulmonary artery systolic pressure >50 mmHg
D) Pressure half-time >220 ms
Answer: D (Pressure half-time >220 ms indicates severe mitral stenosis.)
Which echocardiographic parameter best correlates with RV dysfunction in pulmonary embolism?
A) Tricuspid annular plane systolic excursion (TAPSE)
B) Right atrial size
C) Right ventricular outflow tract velocity
D) LV ejection fraction
Answer: A (TAPSE <16 mm = RV dysfunction.)
A patient with dyspnea undergoes contrast echocardiography. Microbubbles appear in the left atrium within three cardiac cycles. What does this indicate?
A) Left ventricular aneurysm
B) Pulmonary arteriovenous malformation
C) Atrial septal defect (ASD)
D) Patent foramen ovale (PFO)
Answer: C (ASD = Early left-sided bubble appearance due to left-to-right shunting.)
In aortic dissection, which echocardiographic view is most useful for detecting an intimal flap?
A) Apical four-chamber view
B) Parasternal long-axis view
C) Suprasternal notch view
D) Subcostal view
Answer: C (Suprasternal notch view visualizes the aortic arch, where dissections frequently extend.)
In pericardial constriction, which Doppler echocardiographic finding is characteristic?
A) Annulus reversus (medial e’ > lateral e’)
B) Increased E/A ratio
C) Elevated LVOT velocity
D) Increased isovolumic relaxation time
Answer: A (Annulus reversus is unique to constrictive pericarditis.)
Which echocardiographic parameter is used to estimate left atrial pressure in diastolic dysfunction?
A) E/e’ ratio
B) Mitral inflow E/A ratio
C) Pulmonary vein flow reversal
D) LV ejection fraction
Answer: A (E/e’ ratio >15 = elevated left atrial pressure.)
Which cardiac condition typically shows “reverse mismatch” on PET imaging?
A) Hibernating myocardium
B) Takotsubo cardiomyopathy
C) Cardiac sarcoidosis
D) Amyloidosis
Answer: C (Reverse mismatch = Low perfusion but preserved FDG uptake, seen in cardiac sarcoidosis.)
Which pharmacologic stress agent is contraindicated in severe COPD?
A) Adenosine
B) Dobutamine
C) Regadenoson
D) Dipyridamole
Answer: A (Adenosine can cause bronchospasm in COPD.)
A patient with suspected viable myocardium undergoes PET imaging. Which finding suggests myocardial hibernation?
A) Normal perfusion with low FDG uptake
B) Low perfusion with high FDG uptake
C) Fixed perfusion defect
D) No FDG uptake
Answer: B (Low perfusion + high FDG uptake suggests hibernation.)
Which MRI finding is most characteristic of myocarditis?
A) Mid-wall late gadolinium enhancement (LGE)
B) Transmural LGE
C) Patchy subendocardial LGE
D) Homogeneous gadolinium uptake
Answer: A (Mid-wall LGE is classic for myocarditis, unlike ischemic heart disease which involves subendocardium.)
Which cardiac MRI feature is most predictive of sudden cardiac death in hypertrophic cardiomyopathy (HCM)?
A) LV wall thickness >30 mm
B) Global LV hypokinesis
C) Myocardial edema
D) Patchy LGE >15% of LV mass
Answer: D (Extensive LGE (>15% of LV mass) is a strong SCD predictor in HCM.)
Which imaging modality is gold standard for diagnosing coronary artery anomalies?
A) Coronary angiography
B) Cardiac CT angiography
C) Stress echocardiography
D) Nuclear perfusion imaging
Answer: B (Cardiac CT angiography best delineates coronary anomalies.)
A patient with heart failure and LBBB is being evaluated for CRT (cardiac resynchronization therapy). Which imaging technique can predict CRT response?
A) Nuclear perfusion imaging
B) Myocardial strain imaging
C) Cardiac CT
D) Coronary angiography
Answer: B (Myocardial strain imaging detects dyssynchrony, predicting CRT response.)
Which combination of imaging is most useful in cardiac sarcoidosis?
A) Cardiac CT + SPECT
B) PET + Cardiac MRI
C) Echocardiography + Coronary CTA
D) Dobutamine stress echo + Nuclear perfusion imaging
Answer: B (PET detects active inflammation; MRI detects fibrosis.)
