Cardiology MCQs

Cardiology MCQs

Which of the following is an innocent murmur?

1. Gibson’s murmur
2. Roger’s murmur
3. Still’s murmur
4. Dock’s murmur

Correct answer: 3. Still’s murmur

Still’s murmur was described by George Frederic Still in 1909. This is a low pitched murmur heard in the lower left sternal area. It is best heard with the bell of the stethoscope. Still’s murmur is a mid systolic murmur, loudest in supine position and diminishes in intensity on sitting and standing as venous return decreases [Doshi AR. Innocent Heart Murmur. Cureus. 2018 Dec 5;10(12):e3689]. Gibson’s murmur is the train-in-tunnel murmur or machinery murmur of patent ductus arteriosus. Roger’s murmur or Bruit de Roger is heard in small ventricular septal defect. Dock’s murmur is due to stenosis of left anterior descending coronary artery.

Which of the following is NOT a feature of postural orthostatic tachycardia syndrome (POTS)?

1. Heart rate increase ≥30 beats per minute from supine to standing
2. Symptoms get worse with lying down and better on standing
3. Palpitation and light headedness
4. Dependent acrocyanosis

Correct answer: 2. Symptoms get worse with lying down and better on standing

In POTS, symptoms get worse with standing and better on lying down. Dependent acrocyanosis is a striking physical finding which occurs in 40-50% of patients. A dark red-blue discoloration of legs which are cold to touch can be seen [Raj SR. The Postural Tachycardia Syndrome (POTS): pathophysiology, diagnosis & management. Indian Pacing Electrophysiol J. 2006 Apr 1;6(2):84-99].

Bradycardia in — phase of Valsalva maneuver can be easily appreciated by feeling the pulse:

1. Phase I
2. Phase II
3. Phase III
4. Phase IV

Correct answer: 4. Phase IV

Venous return decreases during the strain phase and reduces blood pressure which triggers baroreceptor mediated increase in heart rate. After cessation of straining, there is abrupt reversal resulting in overshoot of arterial pressure, which is known as Valsalva overshoot. This leads to baroreceptor mediated bradycardia. Finally the hemodynamic changes return to basal levels [Junqueira LF Jr. Teaching cardiac autonomic function dynamics employing the Valsalva (Valsalva-Weber) maneuver. Adv Physiol Educ. 2008 Mar;32(1):100-6]. While feeling the pulse during a Valsalva maneuver, it is easy to appreciate the bradycardia during phase IV.

An indexed aortic prosthetic valve orifice area — corresponds to severe stenosis in patient-prosthesis mismatch and needs reoperation:

1. ≤0.60 cm²/m²
2. ≤0.70 cm²/m²
3. ≤0.80 cm²/m²
4. ≤0.90 cm²/m²

Correct answer: 1. ≤0.60 cm²/m²

Indexed effective orifice area of an aortic prosthetic valve should be more than 0.85 cm²/m² to avoid significant gradient at rest and exercise [Pibarot P, Dumesnil JG. Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention. J Am Coll Cardiol. 2000 Oct;36(4):1131-41]. Patient prosthesis-mismatch is an important cause of increased transvalvar gradient detected by Doppler echocardiography. Effective orifice area of an aortic prosthetic valve may be too small in relation to patient’s body surface area and can result in abnormally high gradients.

Wrong statement in relation to left ventricular remodeling:

1. Central pathophysiological mechanism in advancing heart failure
2. Reversal of remodeling with treatment is an important goal in the management of heart failure
3. As the ventricular shape becomes spherical, performance improves
4. Remodeling is initially beneficial as the force of contraction increases

Correct answer: 3. As the ventricular shape becomes spherical, performance improves

Increase in left ventricular volume is initially beneficial as the force of contraction increases according to Starling’s law. Volume overload hypertrophy occurs in the non infarcted segments [McKay RG, Pfeffer MA, Pasternak RC, Markis JE, Come PC, Nakao S, Alderman JD, Ferguson JJ, Safian RD, Grossman W. Left ventricular remodeling after myocardial infarction: a corollary to infarct expansion. Circulation. 1986 Oct;74(4):693-702]. But as the left ventricle assumes a spherical shape later, it leads to decline in performance. Left ventricular cavity was more spherical in those with poorer survival [Douglas PS, Morrow R, Ioli A, Reichek N. Left ventricular shape, afterload and survival in idiopathic dilated cardiomyopathy. J Am Coll Cardiol. 1989 Feb;13(2):311-5]. 

Coarctation of aorta can be best visualized in —- view on echocardiography:

1. Parasternal long axis view
2. Parasternal short axis view
3. Apical four chamber view
4. Suprasternal view

Correct answer: 4. Suprasternal view

Suprasternal view is the standard view for visualizing arch of aorta and proximal part of descending aorta and hence the view for visualization of coarctation of aorta.

Effects of underwater or aquatic treadmill exercise does not include:

1. Useful for senior citizens to avoid the risk of falls and musculoskeletal stress 
2. Useful for obese individuals and those with issues of mobility
3. Increases in BP, HR and RPP are lower with underwater treadmill 
4. There is redistribution of blood volume from thoracic cavity to the lower limbs

Correct answer: 4. There is redistribution of blood volume from thoracic cavity to the lower limbs

Cardiovascular changes occurring during immersions have to be taken into account. There is redistribution of blood volume from the lower limbs to the thoracic cavity. Increases in blood pressure, heart rate and rate pressure product are lower with underwater treadmill walking as compared to walking on a land treadmill [Yoo J, Lim KB, Lee HJ, Kwon YG. Cardiovascular response during submaximal underwater treadmill exercise in stroke patients. Ann Rehabil Med. 2014 Oct;38(5):628-36].

Wrong statement about H₂FPEF score for differentiation of heart failure with preserved ejection fraction (HFpEF) from noncardiac causes of dyspnea:

1. Has clinical and echocardiographic parameters
2. Highest number of points is for age
3. Total score ranges from 0-9
4. Odds of HFpEF doubled for each 1 unit increase in H₂FPEF score

Correct answer: 3. Highest number of points is for age

F Atrial Fibrillation: Paroxysmal or Persistent: 3 points is the highest. E Elder: Age above 60 years has only 1 point. Other parameters are as follows:

H₂ Heavy: Body mass index > 30 Kg/m²: 2 points

     Hypertensive: 2 or more antihypertensive medications: 1 point

P Pulmonary hypertension: Pulmonary artery systolic pressure estimated by Doppler echocardiography > 35 mm Hg: 1 point

F Filling Pressure: Doppler Echocardiographic E/e’ > 9: 1 point

The authors suggested that low H₂FPEF scores of 0 or 1 can be used to effectively rule out the disease, while scores of 6-9 can be used to make a diagnosis of HFpEF with good confidence. Intermediate scores of 2-5 would call for additional testing [Reddy YNV, Carter RE, Obokata M, Redfield MM, Borlaug BA. A Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure With Preserved Ejection Fraction. Circulation. 2018 Aug 28;138(9):861-870].