Acute coronary syndrome, heart failure and hypertension

35 NEET-PG practice questions on Acute coronary syndrome, heart failure and hypertension, part of General Medicine. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Medium

   A 56-year-old farmer reaches a community health centre in rural Rajasthan 2 hours after the onset of crushing chest pain. ECG shows 3 mm ST elevation in V1-V4. The nearest PCI-capable hospital is 4 hours away by road, and he has no contraindication to fibrinolysis. He has received aspirin and clopidogrel. What is the next best step?

   1. ATransfer straight away for primary PCI
   2. BRepeat ECG and troponin in 3 hours
   3. CTenecteplase now, then transfer for angiography
   4. DHeparin alone, with angiography after discharge

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   Answer: C · Tenecteplase now, then transfer for angiography

   Primary PCI is preferred only if it can be done within about 120 minutes of diagnosis; here the delay is far longer. Within 12 hours of onset, fibrinolysis should then be given at once (ideally within 10 minutes of the diagnostic ECG), followed by transfer for angiography: the pharmaco-invasive strategy used in Indian STEMI programmes. Tenecteplase is convenient as a single weight-based bolus. If ST elevation does not settle by at least 50% at 60-90 minutes, rescue PCI is needed.

   • A: The expected delay to PCI exceeds 120 minutes, so waiting loses heart muscle.
   • B: A diagnostic ECG with symptoms is enough; troponin must not delay reperfusion.
   • D: Heparin alone does not open the occluded artery in STEMI.

2. Question 2 · Medium

   Eight weeks after an anterior STEMI that was not reperfused, a 60-year-old man has breathlessness on exertion. His ECG still shows ST elevation with Q waves in V1-V4, unchanged since discharge, and he has no chest pain; troponin is normal. Echo shows a thin, dyskinetic anteroapical segment that bulges outward in systole. The diagnosis is:

   1. ALeft ventricular aneurysm
   2. BDressler syndrome
   3. CVentricular septal rupture
   4. DFresh re-infarction

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   Answer: A · Left ventricular aneurysm

   A transmural infarct that heals as a thin fibrous scar can bulge outward in systole, forming a true left ventricular aneurysm. Persistent ST elevation for weeks after an infarct is its classic ECG sign. Complications include heart failure, ventricular tachycardia and mural thrombus with embolism, so anticoagulation may be needed. Unlike a false aneurysm, a true aneurysm rarely ruptures.

   • B: Dressler syndrome is pericarditis with fever and pleuritic pain.
   • C: Septal rupture gives a new pansystolic murmur and a left-to-right shunt.
   • D: Re-infarction would bring new pain and a rise in troponin.

3. Question 3 · Medium

   A 64-year-old woman from a village near Nagpur is brought to a PCI-capable hospital 14 hours after the onset of chest pain; her family first took her to a local clinic, where she was given antacids. The ECG shows ST elevation with early Q waves in V1-V5. She is cold, clammy and restless, with pulse 116/min, BP 76/48 mmHg despite a fluid challenge, crackles to the mid-zones, SpO2 88% on oxygen and urine output 10 mL/h. Serum lactate is 5.2 mmol/L. What is the most appropriate next step?

   1. AEmergency coronary angiography and PCI
   2. BRoutine balloon pump, then elective angiography
   3. CIV tenecteplase
   4. DMedical therapy, as she is beyond 12 hours

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   Answer: A · Emergency coronary angiography and PCI

   This is cardiogenic shock complicating STEMI. Emergency revascularisation, usually PCI of the culprit artery, is indicated whatever the time since symptom onset, as it improves survival. Inotropes or vasopressors support BP meanwhile; routine intra-aortic balloon pumping did not improve survival in a large trial. Fibrinolysis is much less effective in shock and is used only if PCI cannot be done.

   • B: Routine IABP did not improve survival, and angiography must not be delayed.
   • C: Fibrinolysis works poorly in shock when PCI is available on site.
   • D: The 12-hour window does not apply to shock, where emergency revascularisation is indicated.

4. Question 4 · Medium

   A 57-year-old man is ready for discharge 5 days after an anterior STEMI treated with primary PCI. Echo shows an LV ejection fraction of 32%, and he had signs of heart failure on admission. Potassium is 4.4 mmol/L and creatinine 1.0 mg/dL. Consider: 1. A beta-blocker such as metoprolol succinate. 2. An ACE inhibitor such as ramipril. 3. Eplerenone. 4. Long-acting isosorbide mononitrate. Which of these reduce his mortality?

   1. A1, 2 and 4 only
   2. B1, 2, 3 and 4
   3. C1, 2 and 3 only
   4. D1 and 2 only

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   Answer: C · 1, 2 and 3 only

   Beta-blockers and ACE inhibitors reduce death after MI, particularly with reduced EF, and the aldosterone antagonist eplerenone further reduced mortality in post-MI patients with EF of 40% or less and heart failure (EPHESUS). Statement 4 is wrong: long-acting nitrates relieve angina but do not improve survival. He also needs dual antiplatelet therapy, a high-intensity statin and cardiac rehabilitation. Potassium and creatinine are checked after starting eplerenone.

   • A: Includes nitrates, which relieve symptoms but do not prolong survival.
   • B: Includes statement 4; nitrates have no mortality benefit.
   • D: Omits eplerenone, which lowers mortality after MI with low EF and heart failure.

5. Question 5 · Easy

   A 36-year-old woman has BP 164/102 mmHg on three visits. Serum potassium is 3.1 mmol/L although she takes no diuretic, and she has no features of Cushing syndrome. Which is the best screening test for the likely cause?

   1. AOvernight dexamethasone suppression test
   2. B24-hour urinary metanephrines
   3. CPlasma aldosterone-renin ratio
   4. DRenal artery Doppler study

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   Answer: C · Plasma aldosterone-renin ratio

   Hypertension with unexplained hypokalaemia in a young person suggests primary aldosteronism, the commonest endocrine cause of secondary hypertension. The screening test is the plasma aldosterone-renin ratio: high aldosterone with suppressed renin. A positive screen is confirmed with a suppression test such as saline infusion, then adrenal CT and adrenal vein sampling separate an adenoma from bilateral hyperplasia. Potassium should be corrected before testing.

   • A: Dexamethasone suppression screens for Cushing syndrome, whose features are absent.
   • B: Metanephrines screen for phaeochromocytoma, which causes paroxysms rather than hypokalaemia.
   • D: Renal artery Doppler looks for renovascular disease, a less likely fit here.

6. Question 6 · Hard

   A 19-year-old college athlete is found to have BP 172/104 mmHg at a sports medical; repeat readings over two weeks are similar. His mother and maternal uncle developed hypertension in their twenties, and his mother has had muscle cramps for years. He is not on any medication. Serum sodium 143 mmol/L, potassium 2.9 mmol/L and bicarbonate 32 mmol/L; plasma renin activity and plasma aldosterone are both low. He takes no liquorice, chewing tobacco or herbal products, and 24-hour urinary free cortisol is normal. Renal artery Doppler is normal. Which drug will best control his BP?

   1. ASpironolactone
   2. BAmiloride
   3. CDexamethasone
   4. DHydrochlorothiazide

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7. Question 7 · Medium

   A 58-year-old man has clinic BP 156/96 mmHg despite full doses of amlodipine, telmisartan and chlorthalidone. Pill counts confirm adherence, ambulatory monitoring confirms the high readings, and he has cut his salt intake. Potassium is 4.2 mmol/L, eGFR 70 mL/min/1.73 m², and secondary causes have been excluded. Which drug is the best fourth agent?

   1. ADoxazosin
   2. BClonidine
   3. CSpironolactone
   4. DBisoprolol

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8. Question 8 · Medium

   A 17-year-old boy is found to have BP 168/96 mmHg in the right arm at a college medical examination; he has occasional headaches and his legs tire and cramp when he plays football. BP in the legs could not be recorded reliably. His femoral pulses are weak and delayed compared with the radial pulse, and there is an ejection click with a systolic murmur heard over the back between the scapulae. Chest X-ray shows notching of the lower borders of several ribs. The most likely cause of his hypertension is:

   1. ARenal fibromuscular dysplasia
   2. BPatent ductus arteriosus
   3. CCoarctation of the aorta
   4. DTakayasu arteritis

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9. Question 9 · Medium

   A 60-year-old man who ran out of his amlodipine a week ago comes to the OPD for a refill. He has no headache, chest pain, breathlessness or neurological symptoms. BP is 196/118 mmHg on repeated readings; the fundi show only arteriolar narrowing, and his ECG, urine and creatinine are unchanged from last year. What is the most appropriate management?

   1. ASublingual nifedipine in the OPD
   2. BAdmit for an IV labetalol infusion
   3. CRestart oral drugs and review within days
   4. DIV nitroprusside in the ICU

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10. Question 10 · Easy

    A 70-year-old smoker with hypertension, diabetes and peripheral arterial disease is started on ramipril. Ten days later his creatinine has risen from 1.2 to 2.1 mg/dL. He has had two admissions for sudden pulmonary oedema with normal LV function, and an abdominal bruit is heard. What is the most likely underlying diagnosis?

    1. ABilateral atherosclerotic renal artery stenosis
    2. BFibromuscular dysplasia of the renal arteries
    3. CACE inhibitor-induced interstitial nephritis
    4. DProgressive diabetic nephropathy

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11. Question 11 · Medium

    A 55-year-old woman with ischaemic heart failure (EF 30%) is in sinus rhythm with a resting heart rate of 84/min. She takes sacubitril-valsartan, eplerenone, empagliflozin and carvedilol at the highest dose she tolerates; higher doses made her dizzy. BP 108/70 mmHg. Which added drug would best lower her risk of heart-failure hospitalisation?

    1. AIvabradine
    2. BVerapamil
    3. CAmlodipine
    4. DDiltiazem

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12. Question 12 · Medium

    A 62-year-old man with an acute inferior STEMI becomes dizzy after sublingual nitroglycerin. His BP is now 78/50 mmHg, the jugular venous pressure is raised, and the lung fields are clear. The ECG shows ST elevation in II, III, aVF and in V4R. While reperfusion is arranged, which is the most appropriate immediate step?

    1. AIV furosemide
    2. BIV normal saline bolus
    3. CIV morphine
    4. DIV nitroglycerin infusion

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13. Question 13 · Medium

    A 61-year-old man reaches a taluk hospital with an anterior STEMI 2 hours after his pain began; the nearest PCI centre is 5 hours away. Before giving tenecteplase, the medical officer checks: 1. A haemorrhagic stroke 4 years ago. 2. Tearing back pain with unequal arm pulses, raising suspicion of aortic dissection. 3. BP 160/96 mmHg on arrival. 4. A peptic ulcer treated 3 years ago, now asymptomatic. Which of these are absolute contraindications to fibrinolysis?

    1. A1, 2 and 3 only
    2. B2 and 3 only
    3. C1 and 2 only
    4. D1, 2, 3 and 4

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14. Question 14 · Medium

    A 60-year-old man with heart failure with reduced ejection fraction (EF 28%) on enalapril, bisoprolol, spironolactone and dapagliflozin remains in NYHA class II-III. BP 118/72 mmHg, potassium 4.6 mmol/L, eGFR 62 mL/min/1.73 m². His cardiologist switches enalapril to sacubitril-valsartan. Which precaution is essential?

    1. AStop spironolactone on the same day
    2. BStop enalapril at least 36 hours before
    3. CStop bisoprolol to avoid hypotension
    4. DGive both drugs together for one week

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15. Question 15 · Easy

    A 66-year-old man with heart failure with reduced ejection fraction (EF 30%) remains in NYHA class III despite full doses of guideline therapy. He is in sinus rhythm, and digoxin is added. What is the expected benefit of digoxin in this setting?

    1. AFewer admissions, but no fall in mortality
    2. BLower risk of sudden cardiac death
    3. CLower all-cause mortality
    4. DReversal of ventricular remodelling

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16. Question 16 · Medium

    A 41-year-old schoolteacher in Jaipur is referred because her BP swings between 124/80 and 230/130 mmHg, with spells of throbbing head pain, drenching perspiration and a racing heart that last a few minutes. Plasma free metanephrines are four times the upper limit, and CT shows a 4 cm left adrenal mass. Laparoscopic adrenalectomy is planned. Which drug should be started first to prepare her for surgery?

    1. APropranolol
    2. BFurosemide
    3. CSpironolactone
    4. DPhenoxybenzamine

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17. Question 17 · Medium

    A 56-year-old hypertensive man has sudden tearing pain between the shoulder blades. BP 196/110 mmHg in both arms, pulse 104/min. CT angiography shows a dissection starting beyond the left subclavian artery, with no malperfusion of the limbs or organs. Which drug should be started first?

    1. AIV sodium nitroprusside
    2. BIV hydralazine
    3. CIV esmolol
    4. DSublingual nifedipine

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18. Question 18 · Medium

    A 66-year-old man with diabetes was admitted last night with chest pain at rest. His ECG showed 2 mm ST depression in V4-V6 and his high-sensitivity troponin I is well above the 99th percentile and rising, so NSTEMI is diagnosed and he is in the CCU of a PCI-capable hospital. Despite aspirin, ticagrelor, heparin, IV nitroglycerin and a beta-blocker, his chest pain keeps recurring with fresh ST depression, and he has had a run of ventricular tachycardia. What is the best next step?

    1. AIV tenecteplase
    2. BAngiography after 72 hours
    3. CCoronary angiography within 2 hours
    4. DStress test once pain-free

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19. Question 19 · Hard

    A 63-year-old man with non-ischaemic dilated cardiomyopathy is reviewed in the heart failure clinic of a medical college hospital. He still gets breathless walking 50 metres (NYHA class III) after 4 months of optimised therapy with sacubitril-valsartan, bisoprolol, spironolactone and dapagliflozin at target or maximum tolerated doses. BP is 106/68 mmHg, potassium 4.8 mmol/L and creatinine 1.1 mg/dL. He is in sinus rhythm at 62/min; the ECG shows left bundle branch block with QRS 168 ms, and echo shows an LV ejection fraction of 25%. Coronary angiography last year was normal. What is the best next step?

    1. ACardiac resynchronisation therapy
    2. BAdd digoxin for symptom relief
    3. CAdd ivabradine
    4. DSingle-chamber ICD on its own

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20. Question 20 · Medium

    A 38-year-old woman who smokes has episodes of chest pain at rest in the early morning, each lasting 10-15 minutes. During one episode in the ward, the ECG shows ST elevation in II, III and aVF that settles completely within minutes of sublingual nitrate. Coronary angiography shows no fixed stenosis. Consider: 1. The episodes are due to focal coronary artery spasm. 2. Calcium channel blockers are the mainstay of prevention. 3. Propranolol is the preferred first-line preventive drug. 4. Stopping smoking reduces attacks. Which statements are correct?

    1. A1, 3 and 4 only
    2. B1, 2 and 4 only
    3. C1 and 2 only
    4. D1, 2, 3 and 4

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21. Question 21 · Easy

    A 55-year-old man comes to casualty with chest pain at rest; his ECG shows ST depression in V4-V6 and BP is 132/84 mmHg. On direct questioning he says he took sildenafil 8 hours ago. Which drug must be avoided now?

    1. ASublingual nitroglycerin
    2. BHigh-intensity atorvastatin
    3. CAspirin
    4. DMetoprolol

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22. Question 22 · Hard

    A 72-year-old hypertensive woman was admitted to the medical ward of a district hospital with her first myocardial infarction, an anterior STEMI that presented 30 hours after onset and was therefore not reperfused. She has been pain-free since. On day 4, while straining at stool, she suddenly complains of chest pain, her neck veins fill, and she becomes unresponsive. The monitor shows sinus rhythm at 100/min, but no pulse is felt. Bedside echo shows a large pericardial effusion with right ventricular diastolic collapse; there was no new murmur. CPR is started. What is the most likely diagnosis, and what does she need?

    1. ASeptal rupture; balloon pump and surgical patch
    2. BRe-infarction; repeat fibrinolysis
    3. CFree wall rupture; pericardiocentesis and emergency surgery
    4. DPapillary muscle rupture; urgent mitral valve replacement

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23. Question 23 · Medium

    Five weeks after an inferior wall MI treated with thrombolysis, a 54-year-old man has fever, pleuritic chest pain and a pericardial rub. ESR is 72 mm/h, echo shows a small pericardial effusion, and troponin is not rising. What is the most likely diagnosis?

    1. ARecurrent myocardial infarction
    2. BInfective endocarditis
    3. CVentricular free wall rupture
    4. DDressler (post-MI) syndrome

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24. Question 24 · Hard

    A 65-year-old man is admitted with an acute inferoposterior STEMI and undergoes primary PCI of an occluded right coronary artery. On the ward round, students list statements about mechanical complications after myocardial infarction: 1. Papillary muscle rupture typically presents within the first week with acute pulmonary oedema. 2. The posteromedial papillary muscle ruptures more often than the anterolateral because it has a single blood supply. 3. A ventricular septal rupture produces an oxygen saturation step-up from the right atrium to the right ventricle. 4. Dressler syndrome typically appears within the first 24 hours. Which statements are correct?

    1. A1 and 3 only
    2. B1, 2 and 3 only
    3. C2, 3 and 4 only
    4. D1, 2, 3 and 4

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25. Question 25 · Medium

    A 52-year-old smoker is brought to a secondary-level hospital in Jharkhand with chest pain and sweating. The ECG shows 4 mm ST elevation in V2-V4, the nearest cath lab is more than 3 hours away, and he has no contraindication to fibrinolysis, so he receives aspirin, clopidogrel, enoxaparin and tenecteplase 90 minutes after the start of his pain. Seventy-five minutes after the bolus he still has chest pain, and the ST elevation in V2-V4 has fallen by only 20%. BP is 110/70 mmHg. What is the next best step?

    1. AImmediate transfer for rescue PCI
    2. BContinue heparin and watch for 24 hours
    3. CAdd IV streptokinase
    4. DRepeat the tenecteplase bolus

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