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CardiologyQ001:A60yearmanwhoistype2diabeticisadmittedwithchestpain.HisECGsshowinferiorST elevation of 1 mm in 2 leads. He is thrombolysed with steptokinase. His BMmeasurementis15,andhasmissedhisgliclazidedosetoday.Whatisthebestmanagement?

A.ContinuewithgliclazideB.PRNactrapidtokeeptheBMscontrolledC.IvslidingscaleinsulinD.CommencemetforminE.IgnoretheBMsandfocusonhiscardiacside

Answer:c)ivslidingscaleinsulin.TheDIGAMI study compared "conventional"antidiabetic therapy to intensive insulintherapyconsistingofacuteinsulininfusionduringtheearlyhoursofMIandthricedailysubcutaneousinsulininjectionfortheremainderofthehospitalstayandaminimumof3monthsthereafter.Forpatientswithinsulinandbetterglycaemiccontrol,mortalityofpatientsweredecreasedatoneyear.



CardiologyQ002:A 55 year old patient presentedwith breathlessness and ankle oedema. The bloodpressureis135/80mmHg.Onexamination,herJVPriseswithinspiration.Shehasasoftsystolicmurmurandathirdheartsound.BloodtestsrevealaHb10.5g/dl,WCC7.5x10^9/l,Platelets150x10^9/l,sodium136mmol/l,potassium3.5mmol/l,creatinine140mol/l,urea6mol/l.ECGshowspoorRwaveprogression.Anechocardiogramshowsnopericardialeffusion,theventriclesarestiffandsystolicfunctionismildlyimpaired.Whichofthefollowingisthelikelydiagnosis?

A.RestrictivecardiomyopathyB.DilatedcardiomyopathyC.ConstrictivepericarditisD.IschaemiccardiomyopathyE.Pulmonaryembolus

Answer:a)restrictivecardiomyopathy.Inthisscenario,thesymptomscanbecausedbyanyformofcardiomyopathy.TheriseinJVPwithinspirationsuggestseitherconstrictiveorrestrictivecardiomyopathy.Echocardiography show ing no pericardial effusion and stiffness suggests restrictiverather than constrictive cardiomyopathy. The transmitral dopplers on the echomayshowE/Awavereversalandhighvelocitieswhichmaysuggestrestrictivepicture.This may be due to infiltration due to haemochromatosis, endomyocardial fibrosis,sarcoidosis,myeloma,lymphomaorconnectivetissuedisease.



CardiologyQ003:A40yearoldpatienthadamitralvalvereplacement formitralstenosis1monthago.Shepresentswithfevers,lethargyandrigor.HerbloodtestsrevealHb9.5g/dl,WCC13x10^9/l,platelets500x10^9/l,sodium136mmol/l,potassium4.2mmol/l,ESR90mm/hr,CRP180mg/l.Shealsohas2splinterhaemorrhagesand2+ofbloodonurinedipstick.3setsofbloodculturesaretaken.Whichofthefollowingorganismsismostlikelytobegrowninthebloodcultures?

A.EcoliB.ListeriamonocytogenesC.haemolyticGroupAstreptococcusD.KlebsiellaE.Staphylococcusepidermidis

Answer:e)staphylococcusepidermidis.Inapatientwithprostheticvalve,causescanbedivided intoearly (within60daysofsurgery)andlatestages.Earlyprostheticvalveendocarditis isusuallytheresultofperioperativecontamination.Causativeorganisms includeStaphylococcusepidermidis (30%),Staphylococcusaureus(20%),andgramnegativeaerobes(20%).Late prosthetic valve endocarditis is usually the result of bacteremia from dental orgenitourinarysources,GIsurgery,or intravenousdrugabuse.Thecausativeorganismsare similar to those causing native valve endocarditis. These include Streptococcusviridans(30%),Sepidermidis(30%)andSaureus(12%).



CardiologyQ004:A 65 year old lady has ischaemic cardiomyopathy and symptoms of breathlessnesswalking up one flight of steps. Her breath sounds are clear. Chest X ray showscardiomegaly and clear lung fields. She is currently on frusemide 40mg bd andperindopril4mgatnight.Whatmedicationshouldbeadded?

A.SpironolactoneB.CarvedilolC.DigoxinD.AmiodaroneE.Diltiazem

Answer:b)carvedilol.The twobestoptionsarecarvedilolandspironolactone.BothBblocker trials (CIBIS II,Merit HF, Copernicus) and spironolactone trials (RALES) have shown symptomaticimprovementanddecreasedmortality.Inthispatientwithlittlesignsoffluidoverload,abetablockercanbestartedfirst,andthenspironolactoneaddedaswell.



CardiologyQ005:A55yearoldmanhasprogressiveshortnessofbreathandankleoedema.HehascomefromAfricaoriginallyandgivesahistoryofprobablytuberculosismanyyearsago.On examination,hehas abloodpressureof105/55mmHg, raised JVP+6 cmwith arapidydescentandsignificantankleoedema.Whatisthelikelydiagnosis?

A.CardiactamponadeB.AorticregurgitationC.RestrictivecardiomyopathyD.PericardialconstrictionE.Leftventricularimpairmentcausingheartfailure

Answer:D)pericardialconstriction.Thesignsofpericardialconstriction/constrictivepericarditisarerapidydescent,raisedJVPandKussmaulssign.The ydescent isoftenblunted in cardiac tamponade.A further clue is thehistoryoftuberculosiswhichpredisposestoconstrictivepericarditis.



CardiologyQ006:A75yearoldmanhasbecomeprogressivelymorebreathless.Onexaminationhehasadisplaced cardiac apex and a third heart sound. Chest XR confirms cardiomegaly.AnechocardiogramshowsLeftventriclesizeof6.5cm (



CardiologyQ007:A50yearoldmanhassufferedanuncomplicatedmyocardialinfarct3daysagoandatthemomenthehasnoproblems.Heisatouristandwishestotravelbackhomeassoonaspossible.How soon after an uncomplicated myocardial infarct may a patient travel by flightsafely?

A.3daysB.14daysC.4weeksD.2monthsE.3months

Answer:b)14days.Apatient shouldbe fit to fly14daysafteranuncomplicatedmyocardial infarct,afternormalactivitieshavebeenresumed.ForcomplicatedMIs,thepatienthastowaituntilsymptoms stabilise. Coronary artery bypass graft and other chest surgery recommended wait about 2 weeks so that any air introduced into chest will havebecomeabsorbed.



CardiologyQ008:A65yearoldmanhasanangioplastytotheleftanteriordescendingartery.Inconsideringmedicaltherapy,whichofthefollowingreducesrestenosisratesfollowingangioplasty?

A.AngiotensinconvertingenzymeinhibitorsB.AbciximabC.BetablockersD.LowmolecularweightheparinE.Pravastatin

Answer:b)Abciximab.There is some data to suggest that the use of the antiplatelet glycoprotein IIb/IIIareceptor blocker (abciximab)may reduce the risk or restenosis in both diabetic andnondiabeticpatients.



CardiologyQ009:A50yearoldmanpresentswithpalpitations.HisECGshowsAVdissociation.WhichofthefollowingconditionsismostlikelytocauseAVdissociationonanECG?

A.1stdegreeAVblockB.AtrialflutterC.MobitztypeIIblockD.WenkebachE.Completeheartblock

Answer:e)Completeheartblock.Complete(3rddegree)heartblockandventriculartachycardiaaremost likelytocauseAVdissociationonanECG.



CardiologyQ010:A60yearoldmanhaspalpitations.AnadmissionECGshowsQTcprolongationof0.48s.Whichofthefollowingconditionsmightbeassociated?

A.DigitalisB.HyponatraemiaC.HyperthermiaD.HypocalcaemiaE.Hyperkalaemia

Answer:d)Hypocalcaemia.Hypokalaemia, hypocalcaemia , hypomagnesaemia and hypothermia can causeprolonged QT interval on the ECG. Prolonged QT is classified as a QTc interval(corrected)ofmorethan0.44seconds.



CardiologyQ011:A45yearoldmanhaschestpainwalkinguphills.Whichofthefollowinginvestigationsisthebestforriskstratificationofangina?

A.ECGB.TroponinTC.EchocardiogramD.CoronaryangiogramE.Thalliummyocardialperfusionscan

Answer:b)troponinT.The high risk factors are positive troponin and dynamic ST depression on ECGwithangina.Thoseinthehighriskgroupshouldbereferredforurgentcoronaryangiography.



CardiologyQ012:A65yearoldmanhaspalpitations.HehasabroadcomplextachycardiaontheECG.Inabroadcomplextachycardia.WhichofthefollowingwouldbethestrongestindicationtowardsadiagnosisofVT?

A.DiscordantQRScomplexesinthechestleadsB.ExtremerightaxisdeviationC.HemodynamicinstabilityD.TrifascicularblockonECGE.Cannonawaves

Answer:e)Cannonawaves.Any evidence of AV dissociation such as cannon a waves effectively rules out asupraventricular tachycardia. Features suggestive ofVT, rather than SVTwith bundlebranchblockare:

cannonawavesonJVPfusionand/orcapturebeatsLeftaxisdeviationQRSduration>140msecconcordanceoftheQRScomplexesinthechestleadshistoryofischaemicheartdisease

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CardiologyQ014:A 75 lady was found to have Atrial Fibrillation on her ECG. She has a history ofhypertension.Theratewas85minandBPwas140/85mmHg.Whatmanagementshouldbeconsiderednext?

A.DigoxinB.AspirinC.WarfarinD.DCcardioversionE.Atenolol

Answer:C)Warfarin.Thepatientsheartrate isnotfast.Shescores2ontheCHADS65score(she isaboveage65andshehashypertension)thereisasignificantbenefitinformalanticoagulationwithwarfarininviewoftheriskofthromboembolism



CardiologyQ015:A30yearoldpatientcomplainsofdizzyspells.Uponadmission,hehasanECGwhichshowsaPRintervalof0.6sandQTintervalof0.5s.Whichoneofthefollowingmedicationscouldberesponsible?

A.AspirinB.AmoxycillinC.TerfenadineD.DigoxinE.Acetazolamide

Answer:c)terfenadine.AQT interval of >0.45 is prolonged.Common drugs are tricyclic antidepressants (eg.amitryptiline),quinidine,erythromycin,amiodarone,phenothiazines(chlorpropramide),antihistamines(terfenadine)andgrapefruitjuice.



CardiologyQ016:A65yearoldmanwithdiabetesmellitushasabloodpressureof190/90mmHg.Clinicalexaminationwasnormal.AnECGrevealsevidenceofleftventricularhypertrophy.Whichoneofthefollowingdrugsappropriatetreatmentforhypertension?

A.SodiumnitroprussideB.LabetalolC.AtenololD.DoxazosinE.Bendrofluazide

Answer:e)Bendrofluazide.TheBritishHypertensiveSocietyguidelineswouldsuggesteitheraDiureticorCalciumchannel blocker [C or D for older or black patient]. Although ACE inhibitor isrecommended for diabetic patients, this is not among the options, hence the bestchoiceisthediuretic(D).

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CardiologyQ019:A50yearoldwomanwithpreviousrheumaticheartdiseasehasbeenlosttofollowupfor some time.Shenowhas symptomsofbreathlessness.Onexamination, shehasatappingapexbeat,diastolicmurmurandalargeVwaveintheJVP.Whatisthelikelydiagnosis?

A.IsolatedmitralstenosisB.MixedmitralvalvediseaseC.MitralstenosisandtricuspidregurgitationD.CardiactamponadeE.Aorticregurgitation

Answer:C)mitralstenosisandtricuspidregurgitation.Rheumatic fever has predisposed the patient tow ardsmitral stenosis,whichwouldmanifestassignsofalowrumblingdiastolicmurmurandatappingapexbeat.ThelargeVwave in the JVP suggests tricuspid regurgitationwhich is secondary to pulmonaryhypertension(alsomayhavealoudsecondheartsoundandarightventricularheave).



CardiologyQ020:A33yearoldmanpresentswithchestpainsandfatigueforseveraldays.Hisobservationsshowa temperatureof38C,pulse100bpm,BP100/70mmHg.ECGshows Twave inversion in the anterior and inferior leads. The troponin I is 3 ng/mL(

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CardiologyQ022:A 40 year oldman presented because he is concerned about his family history ofhypertrophicobstructivecardiomyopathy.Hisbrotherhasrecentlydeceasedfromduetothecondition.Whatinvestigationshouldbeoffered?

A.TransthoracicechocardiogramB.TransoesophagealechocardiogramC.ElectrophysiologicalstudyD.CoronaryangiogramE.Cardiacthalliumscan

Answer:A)transthoracicechocardiogram.RelativesofpatientswithHOCMshouldbeofferedscreeningespeciallyinthecontextofa fatality. The best form is transthoracic echocardiogram, and beyond that genetictestingmaybehelpful.



CardiologyQ023:A42yearwomanwhohasreceivedradioactiveiodinemanyyearsagohasroutinebloodtests.Shedoesnothaveanysymptomssuggestiveofangina.Herresultsreveal:

FreeThyroxine10.2pmol/l(9.823)TSH13mU/l(0.54.5mU/l)Totalcholesterol7.8mmol/l(



CardiologyQ024:A65yearoldmanhassymptomsofbreathlessnessandchestpains.Hehascardiacriskfactorsof smoking andelevated cholesterol.Onexamination,hehas aharsh systolicmurmurandquietsecondheartsoundconsistentwithaorticstenosis.Echocardiographyrevealsagradientof75mmHgacrosstheaorticvalve.Whichofthefollowingisthemostusefulinvestigation?

A.TransoesophagealechocardiographyB.CoronaryangiographyC.RightheartcardiaccatheterD.CardiacelectrophysiologicalstudyE.CTpulmonaryangiogram

Answer:B)Coronaryangiography.Thediagnosisissevereaorticstenosiswithsignificantclinicalsymptoms.Thepatientislikely torequiresurgicalaorticvalvereplacement.Alongwith therisk factors, there ishigh risk of coronary artery disease. Coronary angiography should be the nextinvestigationtoinvestigatewhethercoronarybypassgraftsarenecessaryaswell.



CardiologyQ025:A65yearoldmanhadamyocardialinfarction2monthsago.HehashadastentplacedintheLADarteryfollowingangioplasy.DuringaroutinefollowupExerciseTesthehasa15beatrunofnonsustainedVT.ThenonsustainedVToccurredhalfwaythroughStage2.Whatisthenextdefinitiveinvestigation?

A.ThalliumscanB.CardiacelectrophysiologicalstudyC.EchocardiogramD.24hourtaperecordingE.Repeatcoronaryangiography

Answer:b)Cardiacelectrophysiologicalstudy.PostMIVTismostcommonlydueventricularscartissue.ThispatienthashadcoronaryrevascularisationandstillhassignificantrunsofVT.HenceanelectrophysiologicalstudytoattempttostimulateVTisnecessary.IfthestudydemonstratedVT,thenthepatientshouldhaveandefibrillator(ICD)inserted[MADITtrial,AmJCardiol1997;79:167].



CardiologyQ026:A55yearoldmanhaspalpitationsandbroadcomplextachycardiaontheECG.Inabroadcomplex tachycardia,whichof the followingsuggestsadiagnosisofsupraventriculartachycardia(SVT)?

A.CannonawavesB.TerminationwithadenosineC.QRSduration>140msecD.FusionbeatsE.ConcordanceofVleads

Answer:b)Terminationwithadenosine.FeatureswhichfavourofVTinclude:

evidenceofAVdissociation(cannonawavesonJVP)fusionand/orcapturebeatsleftaxisdeviation(between90and180degree)QRSduration>140msecconcordanceofVleads(monophasicQRS)

FeatureswhichfavorofSVT:LongshortcyclesequenceSlowingorterminationbyincreasingvagaltoneorwithadenosineTrileafedQRSinV1RPinterval



CardiologyQ027:A 70 year old man has a history of progressive tiredness and breathlessness. Onexaminationthere ispallor,hispulserate is65beatsperminute,and isslowrising innature.TheJVPisnotelevated.Hisapexbeat isatthe5th left intercostalspacemidclavicular lineand it isheaving innature.Thereisasystolicthrillintherightsternaledgeandthereisasystolicmurmurintheaorticarearadiatingtotheneck.Investigationsreveal:

Hb8.0g/dlMCV70fL.

Uponfurtherinvestigationofthispatientsanaemiathemostusefultestwouldbe:

A.CapsuleendoscopyB.BariumswallowC.ColonoscopyD.CTpneumocolonE.Flexiblesigmoidoscopy

Answer:c)Colonoscopy.Thepatienthasfeaturesofaorticstenosisand irondeficiencyanaemia.Aorticstenosismaybeassociatedwithangiodysplasiaofthecolonandthebesttesttoelucidatethisiscolonoscopy.

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CardiologyQ029:A50yearoldmanpresentswithbroadcomplextachycardia.HehasaBPof100/70anda pulse rate of 170. The duty medical registrar is considering administration ofantiarrhythmics.Whichoneofthefollowingmedicationsiscontraindicatedinthispatient?

A.MagnesiumB.AmiodaroneC.VerapamilD.ProcainamideE.Lignocaine

Answer:c)verapamil.Thepatient is likely tohave ventricular tachycardia in viewof the very fast rate andbroadcomplexes.AllareusefulagentswhichcanbeusedinconjunctioncautiouslyforVTexceptforVerapamil.Verapamil is contraindicated in VT because it can cause the blood pressure to dropdrasticallyduetonegativeionotropicaction.



CardiologyQ030:A65yearoldmanhasasystolicmurmurintheaorticarea.Inassessinghim,whichofthefollowingisaclinicalfeatureofsevereaorticstenosis?

A.LoudmurmurB.SlowrisingpulseC.EnlargedleftatriumD.PalpableapexbeatE.Earlydiastolicmurmur

Answer:b)slowrisingpulse.Theclinicalsignsconsistentwithsevereaorticstenosisare:

Slowrisingpulsecharacter4thheartsoundSoftaortic2ndheartsoundSystolicthrillExtendedlengthofmurmurinsystole



CardiologyQ031:A 60 year old man has had previous myocardial infarction. He has symptoms ofbreathlessnessconsistentwithNYHAclass IIIheartfailure.EchocardiographyshowsanLVejectionfractionof35%.Whichofthefollowingcombinationsofmedicationismostappropriate?

A.ACEinhibitor,blocker,angiotensinIIblockerB.ACEinhibitor,blocker,aldosteroneantagonistC.ACEinhibitor,loopdiureticD.blocker,angiotensinIIblockerE.ACEinhibitor,blocker,statin

Answer:b)ACEinhibitor,blocker,aldosteroneantagonist.Of all the combinations, ACE inhibitor / angiotensin II blocker with blocker andaldosteroneantagonist(spironolactone,eplerenone) isthemostappropriategiventhefact that this patient has symptomatic heart failure. Trials have shown that thesemedicationshaveamortalityandalsosymptomaticbenefit.



CardiologyQ032:A45 yearoldCaucasianmanhashypertension.Hehasabloodpressure consistentlyabove160/90mmHg.Hedoesnothavesignsofmalignanthypertensionorrenalfailure.Whichofthefollowingisthemostappropriateantihypertensive?

A.DiltiazemB.MethyldopaC.SodiumnitroprussideD.LisinoprilE.Bendrofluazide

Answer:D)Lisinopril.AccordingtotheBritishHypertensionSocietyguidelines,apatientwhoisnonblackandunder55yearsofageshouldbeconsideredforanACEinhibitororBetablocker.InthiscasetheACEIlisinoprilisthebestchoice.



CardiologyQ033:A32yearold ladycomplainsofperiodicepisodesofpalpitationsand lightheadednessfor about 2030minutes. It occurred once a week for the last few weeks. An ECGshowednormalsinusrhythm.Whatistheinvestigationofchoice?

A.24hrholtermonitoringB.EchoC.ExercisetestsD.PatientcontrolledLooprecorderE.Electrophysiologicalstudy

Answer:D)PatientcontrolledLooprecorderThe frequency of the symptoms is low , hence a 24 hour tapemay not capture anarrhythmia.Apatientcontrolled looprecorderallowsrecordingofrhythmsaroundthetimeoftheevent,henceamuchhigherlikelihoodofrecordinganabnormalrhythm.



CardiologyQ034:A 61 year old man with a previous history of myocardial infarction, presents withrecurrent loss of consciousness. On examination therewere signs of left ventricularaneurysm.BPwas110/70mmHgandpulseratewas90/min.CTheadwasnormal.Whatisthecauseoflossofconsciousness?

A.VasovagalsyncopeB.PulmonaryembolismC.StrokeD.VentriculartachycardiaE.Hypersensitivecarotidsyndrome

Answer:D)VentriculartachycardiaA patient with ischaemic heart disease and ventricular aneurysm is at high risk ofdevelopingventriculararrhythmias.Thiscancertainlyleadtothelossofconsciousness.



CardiologyQ035:A50yearoldmanhasreversedsplittingofthesecondheartsoundonexamination.Whichofthefollowingconditionsisthisseenin?

A.AtrialseptaldefectB.PulmonaryregurgitatoinC.MildaorticstenosisD.LeftbundlebranchblockE.Ventricularseptaldefect

Answer:d)Leftbundlebranchblock.ReversedsplittingoccurswithreversalofthenormalA2P2pattern.ThusA2maybedelayedaswithsevereaorticstenosis,andleftbundlebranchblock(LBBB).P2mayalsobe early withWolffParkinsonWhite type B and Persistent ductus arteriosus. Atrialseptaldefectsshowwidefixedsplitting,andrightbundlebranchblock(RBBB)haswidesplitting.



CardiologyQ036:With regard to the conducting system of the heart, where are the Purkinje fibressituated?

A.AtthesuperiorportionofthemyocardiumB.InthemiddleofthemyocardiumC.SubendocardialD.TransmuralE.Subepicardial

Answer:c)Subendocardial.ThePurkinjefibresruninasubendocardialposition.Thisresultsindepolarisationoftheheartfromtheendocardiumtotheepicardium.

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CardiologyQ039:A50yearoldmanwhohadanangioplastyasksaboutClopidogrel.WhatisClopidogrel'smodeofaction?

A.ADPreceptorantagonistB.AffectsAPTTC.InhibitscyclooxygenaseD.HydroxymethylCoenzymeAinhibitorE.GlycoproteinIIb/IIIainhibitor

Answer:a)anADPreceptorantagonist.Clopidogrelpreventsplateletaggregation throughantagonismof theADP receptoronplatelets.



CardiologyQ040:A 55 year oldmanwith breathlessness presents toA&E.On examination, he has aninspiratorysystolicfallinarterialpressureof10mmHg.Whichoneofthefollowingismostlikelytobeassociated?

A.MyocardialinfarctionB.PulmonarystenosisC.CardiactamponadeD.PneumoniaE.Myocarditis

Answer:c)cardiactamponade.Pulsus paradoxus is most commonly related to cardiac tamponade. The y descent(diastolic)phase isabsent intamponade.Pulsusparadoxus isdefinedasan inspiratorysystolicfallinarterialpressureof10mmHg.Itnotonlyoccursincardiactamponade,butalsoinmassivePE,severeCOPDandhypotension/shock.



CardiologyQ041:A 70 year oldmanwith complete heart block has had a VVI permanent pacemakerimplantedaweekago.WhatistheECGlikelytoshownow?

A.ProminentpwavesB.DeltawavesC.STdepressionD.ProlongedPRintervalE.LBBB

Answer:e)LBBB.Permanentpacing can be single chamber atrial (e.g.AAI), single chamber ventricular(e.g.VVI)ordualchamber(e.g.DDD).AVVIpacemakerwouldmeanthatthepacingleadisplacedintherightventricle,causingaLBBBpattern.



CardiologyQ042:A27yearoldmanpresentswith lethargy,poorexercisetoleranceandweight loss.Onexaminationhelooksveryslimandhasapulserateof120beatsperminuteregular.Thepulsevolumedecreasesduringinspiration.HisJVP iselevated5cmsandthe level increasesduring inspiration.Onauscultationofthe heart sounds an early diastolic sound is audible at the left sternal edge. Onexaminationoftheabdomenthereis4fingerbreadthsofhepatomegalyandascites.Whatisthediagnosis?

A.MitralvalveprolapseB.MitralstenosisC.ConstrictivepericarditisD.MyocardialinfarctionE.Aorticregurgitation

Answer:c)Constrictivepericarditis.The patient has the clinical features of constrictive pericarditis. In constrictivepericarditis,anearlydiastolic sound isheard (pericardialknock).This sound isdue toturbulence caused by the arrest of rapid ventricular filling into a nondistensiblepericardialsac.



CardiologyQ043:A 70 year oldman has a ninemonth history ofworsening breathlessness.His bloodpressureis120/90mmHg,O2sats89%onair,temperatureis36.5C,thereisasystolicmurmurheardthroughouttheprecordium.Bloodtestsshow

Hb14g/dlWCC5x10^9/lPlatelets280x10^9/lurea7mol/lcreatinine75mol/lsodium142mmol/lpotassium4.2mmol/lcholesterol6.2mmol/ltriglyceride2.1mmol/l

Whichofthefollowingismostlikely?

A.DilatedcardiomyopathyB.AorticregurgitationC.AorticstenosisD.PericardialeffusionE.Coarctationoftheaorta

Answer:c)aorticstenosis.There is evidence of left sided heart failure clinically. The murmur throughout thepraecordium and narrow pulse pressure suggest aortic stenosis. The patient is alsopredisposedtothisbyahighcholesterol.

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CardiologyQ045:A 25 year old biology student presents with palpitations and has the ECG (above)recorded.Adenosineisgivenat6mgand12mgintravenously.Hefeltnauseousforafewsecondsandthereisarhythmchangetosinusrhythm.Howdoesadenosinework?

A.DecreasesensitivityofconductionbundletoelectrolytesB.AlteringPurkinjefiberresponseC.BlockinganaccessorypathwayD.BlockingAVnodeconductionE.QTprolongation

Answer:d)blockingAVnodeconduction.Adenosineworksbyslow ingatrioventricular(AV)conduction,hencebreakingthereentrycircuitwhichcanbeaAVNRTorAVRTinsupraventriculartachycardia.



CardiologyQ046:A 10 year old patient has Down's syndrome. He has over the past year becomeprogressivelymorebreathless,islosingweightandfeelinglethargic.Heisalsobecomingbluewhenrunningwiththedogduringwalks.Whichofthefollowingcardiaclesionsmightberesponsible?

A.AtrialseptaldefectB.AorticregurgitationC.Tetralogyoffallot'sD.MitralstenosisE.Ventricularseptaldefect

Answer:e)ventricularseptaldefect.Anendocardialcushiondefect(betweentheatrialandventricularseptum)canleadtoASDorVSD.WithrapiddeteriorationaVSD ismost likelytocausebreathlessnessandcyanosis.



CardiologyQ047:A60yearoldmanpresentswithcentralcrushingchestpainradiatingto theback.HehasaweakpulseintherightarmandsystolicBPis120mmHgintheleftarm,80mmHgsystolicintherightarm.Whichoneofthefollowingisafeatureofseverityrequiringimmediate(surgical)action?

A.PersistentvomitingB.HeadacheC.PulmonaryoedemaontheCXRD.HypertensionE.Louddiastolicmurmurintheaorticarea

Answer:e)louddiastolicmurmurintheaorticarea.Inaorticdissection,hypertensionshouldbetreatedwithaninfusionsuchaslabetalol.Aloud diastolic murmur in the aortic area suggests aortic regurgitation. Aorticregurgitationandpericardialeffusion (haemopericardium) suggestdissectiondown totheaorticroot.Thesefeatures,orpersistingchestpainsuggestthatthepatientrequirespromptsurgery.

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CardiologyQ049:A70yearoldwomanhasahistoryofpalpitations for4months.AnECGat that timeshowedatrialfibrillation.Shewasgivendigoxin,diureticsandaspirin.Shenowpresentswithtwoshortlivedepisodesofalteredsensationintheleftface,leftarmandleg.Shealsohadintermittentdysphasia.Thereispoorcoordinationofthelefthand.AnechocardiogramwasnormalaswasaCTheadscan.Whatisthemostappropriatenextstepinmanagement?

A.CarotidendarterectomyB.AnticoagulationwithwarfarinC.ClopidogrelD.CorticosteroidtreatmentE.Noaction

Answer:B)anticoagulationwithwarfarin.The patient has thrombotic events related to atrial fibrillation, hence formalanticoagulationisrecommended.TheAgeandstrokegivesheraCHADS65scoreof3.ACHADS65scoreof2orabovesuggeststheneedforwarfarinisation.



CardiologyQ050:A13yearboyhadasyncopalepisode followedbygeneralised jerkingofallhis limbs,whilsthavingdentalfilling.Hewasparticularlynervousabouttheprocedure.Whenhewasassessedincasualty,hisBPwas145/80,O2satswere99%andECGshowednormalsinusrhythm.Whatisthelikelydiagnosis?

A.GeneralisedtonicclonicseizuresB.VasovagalsyncopeC.CarotidsinushypersensitivityD.VFarrestE.Meningitis

Answer:b)vasovagalsyncope.Vasovagalsyncope isnotuncommonduringaprocedurewhichapatient is frightenedof. Theremay be transient brain hypoxiawhichmay caused generalised seizure likeactivity.



CardiologyQ051:A 60 year male diabetic presents to the clinic. He takes metformin 850 mg tds,bendrofluazide 2.5 mg and asprin 75 mg daily. He has had a previous myocardialinfarctionbutiscurrentlasymptomatic.Hisbodymassindexwas33.5kg/m2,hehasapulse of 90 beats perminute and a blood pressure of 160/9mmHg.His cholesterolconcentrationis3.8mmol/l(

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CardiologyQ053:A55yearoldmanpresentedwithchestpain,facialflushingandelevatedjugularvenouspressurebutno legoedema.Hehadbeenexposedtotuberculosis inchildhood,hadastrongly positive tuberculin test and had been followed up in the tuberculosissurveillance program with regular chest xrays, but had never been diagnosed withtuberculosis.Chest xrayonpresentation showed calcifiedplaquesandmasses in thepericardiumandmediastinum.Coronary angiography showed 70% stenosis in the left anterior descending artery.Cardiaccatheterizationshowedequalisationofdiastolicpressuresinallfourchambers,withapositivesquarerootsign.Whatisthelikelydiagnosis?

A.PericardialeffusionB.CardiactamponadeC.ConstrictivepericarditisD.SarcoidosisE.Angina

Answer:c)Constrictivepericarditis.Thecardiaccatheterdatashowsapatternofventriculardiastolicpressurecharacteristicof constrictive pericarditis. Tuberculous pericarditis is seen in 1%2% of all cases ofpulmonary tuberculosisandcan lead toconstriction.Treatment iswithcorticosteroidsandantiTBtherapy.Theatrialwaveformmanifests:

augmentedawave,reflectingenhancedatrialcontractionintoastiffventriclearapidxdescentattributabletosubsequentacceleratedatrialrelaxationasteepydescentreflectingrapid,resistancefreeearlydiastolicfilling.

Right and left heart chamber filling pressures are typically increased and equalized(LVEDP=RVEDP),reflectingthecommonconstrainingeffectsofthepericardium.

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CardiologyQ054:An30yearoldmanpresentswithahistoryofsyncope related toexercise.There isafamilyhistoryofsuddencardiacdeath.Onexamination,thecarotidpulseisjerky,thereisadoubleapicalpulsation.Onauscultationthere isafourthheartsound,anejectionsystolicmurmurheardatthebaseoftheheart.Theinheritanceofthisconditionismostlikely:

A.MitochondrialinheritanceB.XlinkeddominantC.XlinkedrecessiveD.AutosomalrecessiveE.Autosomaldominant

Answer:e)Autosomaldominant.

Hypertrophicobstructive cardiomyopathy ismost commonlyofAutosomaldominantinheritance.Itoccursinatleastonin1,000toonein500ofthegeneralpopulation.



CardiologyQ055:A30yearoldmanisseenannuallyinthecardiacclinic.Duringauscultationofhisheartthereiswidefixedsplittingofthesecondheartsound.Inwhichoffollowingconditionsdoesthisoccur?

A.AtrialseptaldefectB.AorticregurgitationC.ConstrictivepericarditisD.Ebstein'sanomalyE.RightBundleBranchBlock

Answer:a)atrialseptaldefect.WidefixedsplittingisseeninASD.InRBBBthereiswidesplittingofS2butitnotfixed.



CardiologyQ056:A 65 year old lady has recently had a cholecystectomy 2 days ago. She is now verybreathless,hascentralpleuriticchestpainandfeelsdizzy.Sheisonlyabletosayafewwordsandlookspale.Examinationrevealsasinustachycardiaandflowmurmuracrosstheaorticarea.Herbloodpressure is is85 /50mmHg,O2 saturationsare85%on6litresofO2.ECGshowsnonspecificTwaveabnormalities.Whatshouldbethenextmanagementstep?

A.CTpulmonaryangiogramB.IntravenousheparinC.CoronaryangiogramD.ThrombolysiswithtenecteplaseE.Transthoracicechocardiography

Answer:d)thrombolysiswithtenecteplase.Thispatienthasrecentlyhadsurgery,andherpresentationwouldbeconsistentwithlifethreateningmassive pulmonary embolus. She ismedically too unstable towait for adiagnostictestinradiology,thusthrombolysisshouldbedoneimmediately.Ifthisdoesnotworkthenthepatientmayneedventilation,CTtoconfirmthediagnosisandsurgicalembolectomy.



CardiologyQ057:A75 yearoldman isadmittedwith suddenonset shortnessofbreath,poorexercisetoleranceandankleoedema.Whichofthefollowinglaboratorytestwouldidentifythereasonforhispresentation?

A.Alpha1antitrypsinlevelsB.SerumelectrophoresisC.SerumtriglyceridesD.BrainnatriureticpeptideE.Ureaandelectrolytes

Answer:d)Brainnatriureticpeptide.The clinical scenario fitswith acute pulmonary oedema. Brain or B type natriureticpeptide is increasingly used as a marker of congestive heart failure. It has highspecificityforthecondition.It isreleasedbyventricularcardiomyocytesduetostretchaspartofthepathophysiologyofcardiacfailure.

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CardiologyQ059:A45yearold ladyhasprevioushistoryof rheumatic fever.Shehasa loud firstheartsoundandadiastolicmurmursuggestiveofmitralstenosis.Whichoftheseisthebestindicatorofseveremitralstenosis?

A.IncreasedpulsepressureB.ClubbingC.LoudsecondheartsoundandrightparasternalheaveD.TappingapexbeatE.Rumblingmiddiastolicmurmur

Answer:c)loudsecondheartsoundandrightparasternalheave.A loudP2and featuresof rightheart strain is suggestiveofpulmonaryhypertension,henceseveremitralstenosis.



CardiologyQ060:A80yearoldwomanisreferredbyherGPforhighbloodpressure.Overthelastthreemonthsherpressurehasbeenrecordedataround175/80mmHg for3occasions.Shehasabodymassindexof26kg/m2andisanonsmoker.Whichofthefollowingisthemostappropriatetreatmentforherbloodpressure?

A.CalciumchannelblockerB.BetablockerC.AlphaBlockerD.AngiotensinReceptorBlockerE.AngiotensinConvertingEnzyme(ACE)Inhibitor

Answer:a)Calciumchannelblocker.Thispatientisolatedsystolichypertension(systolicBP>160mmHg).Baseduponstudiessuch as the Systolic Hypertension in the Elderly Program (SHEP) the BHS guidelinessuggesttreatmentwitheitherCalciumantagonistsorDiuretics(CorD).



CardiologyQ061:A65yearoldmanexperiences substernalchestpainuponexertion for6months.AnelectrocardiogramshowsTwave inversion in theanterolateral leadsat rest.Hehasatotalserumcholesterolof8mmol/l.Onangiography,hehasa95%narrow ingof theleftanteriordescendingartery.Whichoffollowingeventsislikelyoccurinthispatient?

A.PulmonaryembolismfromaleftventricularmuralthrombusB.PulmonaryembolismfromthrombosisinainternaljugularveinC.AsystemicarteryembolusfromthrombosisinathehepaticveinD.AsystemicarteryembolusfromaleftventricularmuralthrombusE.Asystemicarteryembolusfromaleftatrialappendagethrombus

Answer:d)Asystemicarteryembolusfromaleftventricularmuralthrombus.A significant stenosisof the left anterior descending arterymay lead to infarction ofanterior regionof the leftventricle.Thrombusmay formonanareaof thedyskineticventricle (muralthrombus).Thereforeheatriskofarterialembolusofthrombus fromtheLV.



CardiologyQ062:A60yearoldmanpresentswithsharpchestpainradiatingtotheepigastrium.HehasSTelevation intheanterior leadsonhisECGand isthrombolysed.Thechestpainpersistsdespite thrombolysis.He develops a raised JVP up to the ear lobes andBPdrops to95/60.Therearesignsofpulsusparadoxus.Whatisthelikelydiagnosis?

A.AorticdissectionB.PericarditisC.PulmonaryembolismD.AnteriorMIwithmyocardialruptureE.Patentductusarteriosus

Answer:a)aorticdissection.Aorticdissectioncanpresentwithpainradiatingtotheepigastricregionorback.Ifthedissectionflapinvolvesclosetotheaorticroot,thenthecoronaryflowcanbeaffected,causing either inferior MI in right coronary artery or anterior MI in left anteriordescending artery involvement. Cardiac tamponade can also be caused by dissection(bloodflowingintopericardialspace)andleadingtoaraisedJVPandpulsusparadoxus.



CardiologyQ063:A 60 year oldmanwas admittedwith severe chest pain.On examination his BloodPressurewas205/115mmHg.ECGshowed>2mmSTelevationinLeadsV24.Hewasgivenmorphineandaspirin.Whatisthenextappropriatemanagement?

A.IvtPAB.IvstreptokinaseC.IvGTND.ClopidogrelE.Tirofiban

Answer:C)ivGTNIn thispatient thebloodpressure is toohigh to safely administer thrombolysis.GTNshouldbegivento lowerthebloodpressure inthefirst instanceandtovasodilatethecoronaryarteries.



CardiologyQ064:A72yearoldmanisreviewedatmedicaloutpatientcliniccomplainingoftiredness.Hetakesamiodarone,aspirin,atenololandatorvastatin.Hisheartrateonexaminationis85bpm. Recent 24hr ECG shows sinus rhythm throughout with occasional ventricularectopics.Investigationsreveal:FreeT432nmol/l(922)TSH



CardiologyQ065:A60yearoldmanwhowaspreviouslyasymptomaticsuddenlydevelopssevereanteriorchestpain radiating to theback.Withinminutes,hebecomesunconscious.Hehas ahistoryofhypertension.Onexamination,hehasabloodpressureof120/60mmHgintherightarmand105/55mmHgintheleftarm.Anearlydiastolicmurmurwasaudibleinthelowerleftsternaledge.Whichofthefollowingisthemostlikelydiagnosis?

A.MalignanthypertensionB.InternalcarotidarterydissectionC.AcutemyocardialinfarctionD.AorticdissectionE.Pulmonaryembolus

Answer:d)aorticdissection.Theacutehistoryofsharppainradiatingtothebackissuggestiveofaorticdissection.Inaddition,there ispredisposingriskfactorofhypertensionandhecollapses(suggestingthat the dissection flap may have involved large vessels leading tow ards vascularinsufficiency)andhencetheneurologicalsymptoms.Whentheflapdissectsdowntotheaorticroot,aorticregurgitationmayalsobefound(earlydiastolicmurmur).

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CardiologyQ067:A60yearoldmanhashadamyocardialinfarction.Hispulserateis45andheisfeelinglightheaded.Bloodpressureis90/65.Inwhichoneofthefollowingconditionsistemporarypacing indicatedwhensymptomsarepresent?

A.FirstdegreeheartblockB.WenkebachC.2:1MobitztypeIIheartblockD.LeftbundlebranchblockE.Bifascicularblock

Answer:c)2:1MobitztypeIIheartblock.The first form of second degree heart block,Mobitz type I (Wenkebach) is due toprogressiveprolongationofPR intervalandthenmissingabeat.Mobitztype IIseconddegreeheartblockcanoccurwith2:1(only1QRSisconductedfor2pwaves)or3:1.Inapatientwho is compromisedwith symptoms andhypotension, temporarypacing isindicated.



CardiologyQ068:A60yearoldwomanhasatrialfibrillationcontrolledwithdigoxinandbetablocker.Shehas a previous history of hypothyroidism but her last thyroid function tests werenormal.Shefeelslightheadedandisbroughttohospital.Herrenalfunctionisabnormalandshehasapulserateof35.Whatisthelikelydiagnosis?

A.MyxedemacrisisB.AddisoniancrisisC.HypercalcaemiaD.SicksinussyndromeE.Digoxintoxicity

Answer:E)digoxintoxicity.Factors which predispose to digoxin toxicity are renal impairment, hypokalaemia,hypomagnesaemiaandhypercalcaemia. Itcan lead tobradyarrhythmias firstdegreeheart block andWenkebach (Mobitz type II second degree heart block is rare), andcompleteheartblock.Otherfeaturesofdigoxintoxicityarexanthopsia (yellowvision),nausea&vomitinganddyspnoea.ThereversedticksignontheECGisnotafeatureoftoxicitybutisassociatedwithdigoxinuse.



CardiologyQ069:A75yearoldmanwithdilatedcardiomyopathyremainssymptomatic inNYHAclass2group.He has chronic heart failure. On examination his BP 150/95.He is currentlytakingRamipril10mgodandFrusemide80mgOD.Whatisthebesttreatmentoption?

A.LosartanB.AmiodaroneC.BisoprololD.DigoxinE.Spironolactone

Answer:c)Bisoprolol.Beta blockers improvemortality quality of life in chronic heart failure (COPERNICUS,MERITHF,CIBIStrials).Theyshouldbe initiatedoncepatientsarestable(ratherthanintheacutesetting)andcanbeusedinallclassesofheartfailure.



CardiologyQ070:A50yearoldladyhaspalpitations.HerECGshowsabroadcomplextachycardia.Whichofthesefeaturessuggeststhatthetachycardiaismorelikelytobeofventricularorigin?

A.QRSof180msB.LeftbundlebranchblockandleftaxisdeviationC.PwaveforeveryQRScomplexD.HistoryofatrialfibrillationE.Heartrateof150

Answer:a)QRSof180ms.FeaturesthatfavourVT:

QRSof>140msdissociatedpwaveshistoryofischaemicheartdiseaserightbundlebranchblockwithleftaxisdeviationHR>170beatsperminute



CardiologyQ071:A50yearoldwomanhasnewsymptomsofpalpitations.Shehasnopreviouscardiachistory.AnECGrevealsatrialfibrillation.Whichoneofthefollowingdrugsismostlikelytorestoresinusrhythm?

A.DiltiazemB.DigoxinC.AtenololD.FlecainideE.Labetalol

Answer:d)flecainide.Flecainide is a class Ic antiarrhythmic drug. It helps restoration of sinus rhythm andpreventrecurrenceofAF.FlecainidemayprolongQTinterval.ThedrugwasusedintheCardiac Arrhythmia Suppression Trial (CAST) trial, andwas associatedwith increasedmortalityinpatientswithischaemicheartdisease.



CardiologyQ072:A53yearoldmanpresentswithseverecrushingchestpains.HisECGshoweddominantRwavesinV1andV2leads.TheTwaveswerealsotall.Whatisthemostlikelycause?

A.LateralMIB.AnteriorMIC.InferiorMID.PosteriorMIE.Pulmonaryembolism

Answer:D)posteriorMI.The changes of posterior myocardial infarction are seen indirectly in the anteriorprecordialleads.LeadsV1toV3facetheendocardialsurfaceoftheposteriorwalloftheleft ventricle. As these leads record from the opposite side of the heart instead ofdirectlyovertheinfarct,thechangesofposteriorinfarctionarereversedintheseleads.TheRwavesincreaseinsize,becomingbroaderanddominant,andareassociatedwithSTdepressionanduprightTwaves.

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CardiologyQ074:A60yearoldmanisacutelyshortofbreath.ECGshowsatrialfibrillation.HisHRis170andBPis110/70.TherearenocardiacmurmursbuthehasaraisedJVPandfewbasalcracklesinthelungs.Whichoftheseisthebestmanagementstrategy?

A.Atenolol,frusemide,lowmolecularweightheparinB.DigoxinandlowmolecularweightheparinC.Ivamiodarone,ivfrusemideD.Digoxin,frusemide,lowmolecularweightheparinE.FrusemideandDCcardioversion

Answer:d)digoxin,frusemide,lowmolecularweightheparin.The patient has evidence of pulmonary oedema related to tachycardia and AF. Sheneeds anticoagulation, rate control and diuresis to relieve pulmonary oedema. Inaddition, if her blood pressure allows, a nitrate (GTN) infusionwould be helpful.DCcardioversionshouldbeconsideredifratecontrolispoorbutisassociatedwithhighriskofthromboembolismiftheAFisnotnew.

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CardiologyQ076:A55yearoldAfroCaribbeanman intheoutpatientclinichasuncomplicatedessentialhypertension.Hisbloodpressuretoday is160/100mmHgdespiteoptimizationofnonpharmacologicaltherapy.Whichoneofthefollowingdrugsshouldbeused?

A.Atenolol50mgodB.Amlodipine5mgodC.Enalapril5mgbdD.Nifedipine10mgtdsE.Lisinopril2.5mgod

Answer:b)Amlodipine5mgod.Studies indicatethatdrugssuchasACE(angiotensinconvertingenzyme) inhibitorsandBetareceptorantagonistsare lesseffective inAfroCaribbeans.Thereasonappears tobe related to the finding that the reninangiotensinaldosterone (RAA) system iscommonlysuppressed inthemajorityofAfroCaribbeans.Assuch,drugsthatsuppresstheRAAsystemarelesslikelytobeeffective.Calciumchannel blockers (CCBs) and diuretics appear to be more effective in thissubgroup. Shortacting CCBs do not provide prolonged BP control, can cause reflextachycardiaandmaybeassociatedwithhighermortality.Therefore, longactingCCBshouldbethe firstlinedrugofchoice. Ideally,aoncedailyagentwith thatprovidesasmooth24hourBPcontrol (e.g.NifedipineLA30mgodorAmlodipine5mgod).



CardiologyQ077:A 65 year old patient diagnosed as having myocardial infarction on admission tohospital.4days laterhe suffered an attackofprolonged chestpainwhile still in thehospital.WhichoftheenzymeswouldbesthelpindiagnosingapossiblesecondMI?

A.TroponinIB.TroponinTC.LDHD.CKMBE.CK

Answer:d)CKMB.Troponinstendtobeelevated forupto14days.CKMBcomesdown tonormal levelwithin4872hours,andisthemostspecificoftheCKenzymes.Within4daysofthefirstMI,theCKMBfractionshouldnotberaised,andifso,indicatesapossiblesecondMI.



CardiologyQ078:A65yearoldpatienthashadapreviousmyocardialinfarction5yearsagofollowedbycoronary artery bypass grafting. She is on aspirin, ramipril and furosemide. Duringreview,sheiswell.Bloodpressureis140/70mmHg,pulseis80andregular,JVPisnotraised.Herbreathsoundsareclear.Whichdrugshouldbeconsidered?

A.DigoxinB.LisinoprilC.CarvedilolD.ClopidogrelE.Tirofibran

Answer:C)Carvedilol.TheCarvedilolProspectiveRandomizedCumulativeSurvivalStudyinpatientwithseverechronic heart failure was stopped early because of a significant beneficial effect ofcarvedilolonsurvival.

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CardiologyQ080:A25yearoldman isbrought intohospitalwith symptomsofalcohol intoxication.Aninitial ECG reveals atrial fibirillation. The next morning he was found to havespontaneouslyrevertedtosinusrhythm.Anechocardiogramisnormal.Whatistheappropriatemanagement?

A.AdvicetostopdrinkingB.AmiodaroneC.SotalolD.Aspirin3monthsE.Warfarinforonemonth

Answer:a)Advicetostopdrinking.ExcessiveAlcoholisawellrecognizedcauseofatrialfibirillation,likelytobethecauseinthiscase. Ischaemicheartdisease isunlikely,as isstructuralheartdisease inviewofanormal echocardiogram. Therefore, advice to stop drinking is most likely to helpmaintainsinusrhythm.



CardiologyQ081:A60yearoldsecurityguardpresentswithsuddenonsetofseverecrushingcentralchestpain.TheE.C.GshowssinusbradycardiawithSTsegmentelevationinleadsII,III,aVF.Whereisthelikelylesion?

A.DiagonalarteryB.LeftanteriordescendingC.RightcoronaryarteryD.CircumflexarteryE.Obtusemarginalartery

Answer:c)Rightcoronaryartery.The patient has an inferior myocardial infarction. This area of the myocardium issuppliedbytherightcoronaryartery.Thesinoatrialnode isalsosuppliedbyanarterywhich arises from the right coronary artery and hence theremay be bradycardia orheartblock.



CardiologyQ082:A65yearoldmanhaspresentedwithchestpainandhasanteriorSTelevationontheECG which is thrombolysed with tenecteplase. He becomes very breathless. Onexamination, he has a loud pansystolicmurmur in the lower left sternal edge andbilateralcoarsecrepitationsinthelungbases.Whichofthefollowinginvestigationsismostimportanttoconfirmthediagnosis?

A.ChestXrayB.TransthoracicechocardiogramC.CTpulmonaryangiogramD.RepeatECGE.Arterialbloodgas

Answer:b)transthoracicechocardiogram.Althoughhe is likelytohavepulmonaryoedema,aCXRwillnotconfirmthediagnosis.Witha largeanteroseptalMI,hecouldhaveeitherhavemitralregurgitation(functionorpapillarymuscledamage)oraVSDcausingthesystolicmurmur.Asthisisinthelowerleftsternaledge,itwouldbeimportanttogetanurgentechocardiogramtoconfirmandreferforcardiothoracicsurgery.



CardiologyQ083:A55yearoldwomanhasasystolicmurmurwhichisdiscoveredbytheGPwhoreferredthepatientforacardiacopinion.Shehasatransthoracicechocardiogramwhichshowsnormalleftventricularfunction.Thereisnosignificantcardiacenlargementandshehasamitralvalveprolapsewithmoderatemitralregurgitation.The leftatriumdiameter is4.3cm.Whatisthemostappropriatecourseofaction?

A.NoendocarditisprophylaxisnecessaryB.RegularoutpatientfollowupwithechocardiographyC.AnticoagulationwithwarfarinD.TransoesphagealechocardiographyE.Referforcardiacsurgery

Answer:B)Regularoutpatientfollowupwithechocardiography.The normal left ventricular function and dimensions, as well as moderate mitralregurgitationsuggeststhatcardiacsurgerycanbeheldoff.She is insinusrhythmanddoesnotrequireanticoagulation(leftatriumisonlymildlyenlarged



CardiologyQ084:A 40 year old patient has a transthoracic echocardiogram as a follow up. He has adiagnosis of hypertrophic obstructive cardiomyopathy. Clinically he has a systolicmurmurheardloudestintherightuppersternaledge.HisECGshowsgrosslylargeQRScomplexeswithLVHstrainpattern.Whichofthefollowingsuggestshighestriskforsuddendeath?

A.Aleftventricularoutflowtractgradientof20mmHgB.TricuspidregurgitationC.SystolicanteriormotionofmitralvalveD.ECGshowingventricularectopicsE.Interventricularseptalthicknessof4cm

Answer:e)interventricularseptalthicknessof4cm.TheLVoutflowtractgradientisnotsignificantlyhighinthispatient,however,thismaybe variablewithexercise. The large interventricular septal thicknessof4 cm (normal



CardiologyQ085:A60yearoldmanpresentswithbreathlessness,visualblurringandheadachestoA&E.Duringexamination,hehasageneralisedtonicclonicseizure.Hehasabloodpressureof 240/120. Fundoscopy reveals retinal haemorrhages and exudates. The optic discmarginisnotvisualised.Whichofthefollowingmedicationsisfirstline?

A.SodiumnitroprussideB.LabetalolC.DiltiazemD.AtenololE.Bendrofluazide

Answer:a)sodiumnitroprusside.Malignant hypertension can presentwith pulmonary oedema, chest pain, headache,visual disturbance and also seizures. A fundoscopic examination may reveal flameshapedretinalhemorrhages,softexudates,orpapilledema.SodiumNitroprussidehas an immediateonsetof action and shorthalflife. It actsbycausingrelaxationofvascularsmoothmuscle,resultinginvasodilationandinotropy.Thedose is 0.2510 mcg/kg/min IV. IV hydralazine, beta blockers and calcium channelblockerscanalsobeused.



CardiologyQ086:A35yearoldpatientwithmildmitralstenosishasatrialfibrillation.ShepresentsunwellwithfastAFandwasDCcardiovertedsuccessfully.Whichofthefollowingmedicationsismosteffectiveformaintenanceofsinusrhythm?

A.DigoxinB.AmiodaroneC.AtenololD.DiltiazemE.Labetalol

Answer:b)amiodarone.Amiodaroneismosteffectiveformaintenanceofsinusrhythm.However,becauseofitssideeffectprofile,inayoungpatient,itisusuallyworthtryingabetablockerorcalciumblockerbeforetreatingwithamiodarone.

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CardiologyQ088:A 60 year old lady is known to have severe mitral stenosis. She presents withbreathlessness.Onexamination,whichoneofthefollowingfeaturesisexpected?

A.ClubbingB.LoudfirstheartsoundC.WidepulsepressureD.EjectionsystolicmurmurE.Smallleftatrium

Answer:b)loudfirstheartsound.A loud first heart sound and tapping apex beat are common in significant mitralstenosis.Anarrowpulsepressure isexpected in severemitral stenosis. Leftatrium isinevitablydilatedonCXRandechocardiography.



CardiologyQ089:A45yearoldpatienthasbeencommencedonnifedipineforhypertension.Whichofthefollowingeffectdescribestheactionofnifedipine?

A.ReducedsympatheticactivityB.DecreasedactivationofreninangiotensinaldosteroneaxisC.ReducedperipheralcapillarypressureD.ReducedperipheralvascularresistanceE.Decreasevascularreleaseofnitricoxide

Answer:d)reducedperipheralvascularresistance.Nifedipine isadihydropyridine.Themechanismofaction issmoothmusclerelaxationandreduction inperipheralvascularresistance.However,peripheralcapillarypressureis increased(thiscausesoedema intheankles),there is increasedsympatheticactivityand increased activation of the renin angiotensin aldosterone axis. There is alsoincreasedvascularreleaseofnitricoxide.



CardiologyQ090:A70yearmanhasbeenshortofbreathfor1year.AnelectrocardiogramshowsTwaveinversionandqwaves in theanterolateral leadsat rest.Hehas cardiomegalyon thechestXray.Clinicalexaminationshowsathirdheartsound,asoftsystolicmurmurinthemitralareaandalsobilateralinspiratorycrepitationsinhislungs.Whichofthefollowingisheatriskof?

A.DeepveinthrombosisB.PulmonaryembolusC.SystemicarterialembolusfrommuralthrombusD.VenousthrombosisduetomuralthrombusE.Coronaryarterythrombusduetomuralthrombus

Answer:c)systemicarterialembolusfrommuralthrombus.Thismanhas features indicating thathehasanenlarged left ventricle frompreviousanteriormyocardial infarction intheLADarteryterritory.PoorLVfunctionalsocauseshissymptomsofheartfailure.Heisatriskofdevelopingmuralthrombuswithembolustothearterialcirculation.



CardiologyQ091:A45yearoldmanwasreferredbytheGPforevaluationofamurmur.Onexamination,hewasfoundtohaveaslowrisingpulseandejectionsystolicmurmurintheaorticarea.Aorticstenosiswassuspected.Inapatientpresentingwithaorticstenosis,whichoffollowingfeatureswouldbehelpfulinestablishingadiagnosisofcongenitalbicuspidvalve?

A.CalcifiedleafletsB.OldageC.AsystolicejectionclickD.CommissuralfusionontheechocardiogramE.Historyofrheumaticfever

Answer:c)asystolicejectionclick.Anaorticejectionsound(ejectionclick)soonafterS1isespeciallycommonifabicuspidaorticvalveispresent.



CardiologyQ092A40 yearold ladyhaspresentedwithbreathlessness.Her JVP isnoted tobe raised.ManometryrevealsarapidYdescent.On examination, she has hepatomegaly, ascites and ankle oedema. What is thediagnosis?

A.DilatedcardiomyopathyB.LeftventricularfailureC.ConstrictivepericarditisD.PericarditisE.Myocardialinfarction

Answer:c)constrictivepericarditis.Constrictivepericarditisleadstosignsofrightsidedheartfailurewhicharelistedabove.ThereisalsoaprominentandrapidXandYdescentofthewaveform.



CardiologyQ093A57yearoldladywhohadapasthistoryofMyocardialInfarctionandsubsequentCABGwas known to have left ventricular dysfunction on the echocardiogram. She has nosymptomsatpresent.Shewasonaspirin,ramiprilanddiuretic.Onexamination therewerenosignsofheartfailure.Whatdrugshouldbeaddednext?

A.AmlodipineB.BisoprololC.ClopidogrelD.AtorvastatinE.Digoxin

Answer:B)Carvedilol.In a patient with left ventricular dysfunction and known history of ischaemic heartdisease,abetablockershouldbeadded(CIBISIIStudy).



CardiologyQ094A35yearold ladyhasprogressiveshortnessofbreath.Followinganechocardiogram,she is found to have likely rheumatic mitral stenosis is now being considered forpercutaneousmitralvalvuloplasty.Whichofthefollowingwouldcontraindicatethisprocedure?

A.DilatedleftatriumB.AtrialfibrillationC.AorticregurgitationD.HeavycalcificationofthemitralvalveE.Longhistoryofmitralstenosis

Answer:d)heavycalcificationofthemitralvalve.The contraindications tow ards valvuloplasty are heavyMV calcification, thrombus inthe left atrial appendage on transoesophageal echocardiography and severe mitralregurgitation.Thesepatientsareindicatedformitralvalvesurgeryinstead.



CardiologyQ095A25yearoldmanwhosebrotherhadhypertrophiccardiomyopathywasreferredforacardiologicalassessment.Hisechocardiogramconfirmedthecondition.Whichoneoffollowingechocardiographicfeaturesisthemostimportantriskfactorforsuddencardiacdeath?

A.ThicknessofseptalwallB.SystolicanteriormotionofthemitralvalveC.SeverityofmitralregurgitationD.GradientacrossleftventricularoutflowtractE.Anenlargedleftatrium

Answer:a)Thicknessofseptalwall.Thegreater thicknessof septum, themore likelihoodof left ventricularoutflow tractobstruction.Thenextmost importantfactorwouldbethegradientacrosstheoutflowtract.



CardiologyQ096A 55 year old patient hadmyocardial infarction 6 days ago. He suddenly developsdyspnoea,coughandfrothysputum.Forthefirsttimeaharshsystolicmurmurisheardoverthepraecordium.Thissequenceofeventsmightbecausedby:

A.PulmonaryembolismB.AorticdissectionC.TricuspidregurgitationD.RupturedpapillarymuscleE.Rupturedaorticcusp

Answer:d)rupturedpapillarymuscle.FollowinganMI,rupturedpapillarymuscleor interventricularseptum ismost likelytocause the combination of pulmonary oedema and new murmur (either mitralregurgitationorduetoVSD).



CardiologyQ097A30yearoldmanisbroughttoA&Ewithsevereacutechestpainradiatingtotheback.Heispaleandanxious.Onexamination thebloodpressure is150/90mmHg andhewasnoted tohavebluesclerae.Whichofthefollowingconditionshaspredisposedtothiscomplication?

A.CoarctationoftheaortaB.IschaemicheartdiseaseC.RheumaticfeverD.HypertrophiccardiomyopathyE.Marfan'ssyndrome

Answer:e)Marfan'ssyndrome.Marfan'ssyndrome isoneofthecausesofbluesclerae.Theclinicaldiagnosis isaorticdissection.Otherpredisposingdisorderstoaorticdissectionare:essentialhypertension,atherosclerosis ,bicuspidaorticvalve,connectivetissuedisorders,Marfanssyndrome,EhlersDanlossyndrome,adultpolycystickidneydisease.

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CardiologyQ100A 62 year old lady with known congestive heart failure and renal impairment. Shepresentswith features ofworsening heart failure, and alsomentioned about recentdecreasedurineoutput.Whatisthemostusefulinvestigationforthecurrentcondition?

A.ElectrolytesB.UreaC.CreatinineD.EchocardiogramE.Chestxray

Answer:D)echocardiogram.Apatientwithsymptomsofcongestivecardiacfailureandrenal impairmentmayhavedeterioratingleftventricularfunction.Thismaysubsequentlyleadtocardiogenicshock,theseverityofLVfunctionshouldbedocumentedtoguidefurthermanagement.



CardiologyQ101A28yearwomanwhois20weekspregnantisseenintheoutpatientclinicandnotedtohaveasustainedbloodpressureof180/95mmHg.Whatisthemostappropriateantihypertensivetherapyforthispatient?

A.MethyldopaB.HydralazineC.NifedipineD.LisinoprilE.Atenolol

Answer:a)Methyldopa.Methyldopaisthesafestagenttouseinthefirstandsecondtrimesterofpregnancy.Betablockersmaycauseintrauterinegrowthretardation.ACEinhibitorshavealsobeensuggestedtohaveteratogeniceffects.



CardiologyQ102Acardiactechnicianhasdoneanechocardiogramandrefersthepatienttoyouwithareport.Whichoneofthefollowingmeasuresisessentialforthecalculationofejectionfraction?

A.VentricularwallthicknessB.AorticvalvediameterC.LeftventricularenddiastolicdiameterD.StrokevolumeE.Aorticvalvevelocity

Answer:C)Leftventricularenddiastolicdiameter.Ejection fractionmeasurement requiresmeasurements during both the end systolicphaseorenddiastolicphasesonthetransthoracicechocardiogram.Thiscouldbeintheform of ventricular diameter measurement or area of the ventricle (in both casesvolumes are estimated by the echo machine). The end systolic and end diastolicvolumesarethensubtractedtoobtainanejectionfraction.Strokevolume itself isnotsufficient to give the ejection fraction hence needs comparison either systolic ordiastolicmeasurements.



CardiologyQ103A55yearoldmanwithanginahasfamilialhypercholesterolaemia.Hisfatherandunclebothhavecoronaryheartdisease.Whichoneofthefollowingisatypicalfeatureforthecondition?

A.PlantarxanthomasB.AutosomalrecessiveC.IncreasedLDLconcentrationsD.HypertriglyceridaemiaE.IncreasedexpressionofLDLreceptors

Answer:c)increasedLDLconcentrations.Familial hypercholesterolaemia is an autosomal dominant condition. There areincreased LDL concentrations due to reduced numbers of LDL receptors.Hypertriglyceridaemia does not usually occur and HDL concentrations are usuallydecreased.Tendonxanthomasoccur,notplantarxanthomas.



CardiologyQ104A48yearoldmaleisreferredwithimpotence.Hehasahistoryofangina,hypertensionandtype2diabetes.Which one of the following drugs that he takes would present a contraindicationtowardshimreceivingSildenafil?

A.AspirinB.BendrofluazideC.IsosorbideMononitrateD.LisinoprilE.Metformin

Answer:C)Isosorbidemononitrate.Thereisasignificantriskofhypotensionwhensildenafilisusedwithnitrates.Henceitiscontraindicatedinpatientswithahistoryofanginaorischaemicheartdisease.



CardiologyQ105A 65 year oldwomanwho is on digoxin has symptoms of nausea and dizziness.Onexamination,herheartrateis35bpmandanECGshowsprolongedPRintervalwithfirstdegreeheartblock.Digoxintoxicityismorelikelywithwhichofthefollowingconditions?

A.HypocalcaemiaB.HypothyroidismC.RamipriluseD.HyperkalaemiaE.Hypokalaemia

Answer:e)Hypokalaemia.Hypomagnesaemia, hypokalaemia, and hypercalcaemia are common metabolicdisturbanceswhichmayworsendigoxintoxicity.Bradycardia,prolongedPR interval, shortenedQT intervaland various formsofheartblockcanoccurindigoxintoxicity.



CardiologyQ106A70yearoldmanhasahistoryofsyncope.He is foundtohaverunsofnonsustainedventricular tachycardia on ECGs done in casualty. He has a pastmedical history ofhypertension.Investigationsshowaserummagnesiumof0.6mmol/l(0.751).Whichoneofthefollowingisthemostlikelycauseofhypomagnesaemia?

A.CalciumchannelblockersB.DiuretictherapyC.HyperphosphataemiaD.DiarrhoeaandvomitingE.Hypercalcaemia

Answer:b)Diuretictherapy.Magnesium ispresent ingreatestconcentrationwithinthecelland isthesecondmostabundant intracellular cationafterpotassium.Most renal reabsorptionofmagnesiumoccursintheproximaltubuleandthethickascendinglimboftheloopofHenle.Significantlossesofmagnesiumthatresultinhypomagnesemiamayresultfromchronicdiarrhea,laxativeabuse,inflammatoryboweldisease,orneoplasm,diuretics(thiazide,loopdiuretics).



CardiologyQ107A55yearoldladyhasdentalphobiabuthasfinallygonetothedentistfollowingseveretoothachesandistoldshehasdentalabscesses.SheisbroughtintoA+Ewithhighfeversbyarelative.Sheisfoundtohaveadiastolicmurmurintheaorticarea.Whichoneoftheseisasignofendocarditis?

A.RoslynsSpotB.HepatomegalyC.LossofperipheralpulsesD.PulmonaryfibrosisE.Bloodonurinedipstick

Answer:e)bloodonurinedipstick.Blood on the urine dipstick indicates renal vasculitis due to microemboli fromvegetationsinendocarditis.Oslersnodesaresmallreddishtenderareasonthepulpoffingersortoes.Janewaylesionsarereddishspotsonfingersortoes,butarepainless.Splenomegalyoccurs.Roth'sspotsarevasculiticlesionsontheretina.Bouchardsnodesoccurinosteoarthritis.



CardiologyQ108A30yearold ladywasdiagnosedwith longQTsyndromeon routine investigation forherinsurancescheme.Whichoneofthefollowingdrugsshouldbestarted?

A.AtenololB.DigoxinC.AmiodaroneD.VerapamilE.Lignocaine

Answer:A)AtenololIn themanagement of a case of congenital LQT syndrome, betablockade is usuallyeffective inpreventingventriculartachyarrhythmiasinthepatient.Ifsymptomaticor ifthereareventriculararrhythmiasdocumented,anintracardiaccardioverterdefibrillatorshouldbeconsidered.



CardiologyQ109A23yearoldmalepresentedwitha2yearhistoryofbreathlessnessonexertion.On examination, therewas a systolicmurmur in the pulmonary area andwide fixedsplittingofthesecondheartsound.Inwhichoftheseconditionsisfixedandwidesplittingofthesecondheartsoundseen?

A.Fallot'stetralogyB.VentricularseptaldefectC.AtrialseptaldefectD.PulmonarystenosisE.Aorticregurgitation

Answer:c)Atrialseptaldefect.ThesecondheartsoundtypicallyoccurswithA2(aortic)andP2(pulmonary).Widesplittingcanoccurwithdelayedpulmonaryclosure(P2)asinrightbundlebranchblock (RBBB),pulmonarystenosisandventricularseptaldefect (VSD).However,FIXEDwidesplittingonlyoccursinASD.



CardiologyQ110A 65 year old man with a history of previous myocardial infarction presents withpalpitations.TheECGshowsabroadcomplextachycardiaatarateof150beats/minandabloodpressureof90/55mmHg.Thefirstlinetreatmentshouldbe:

A.SotalolB.FlecainideC.VerapamilD.AmiodaroneE.Lignocaine

Answer:d)Amiodarone.The likelydiagnosis isventricular tachycardia.Thereareearly signsofhaemodynamicinstability(bloodpressureislow).Inthiscase,amiodaroneisthebestagentasfirstline.Lignocaine and flecainide can also be used but are not considered first line whenpatientsareunstable.



CardiologyQ111A50yearoldtaxidriverisfollowedup8weeksafterananteriormyocardialinfarction.He underwent rescue angioplasty with stenting to the LAD vessel following failedthrombolysis.Sincethenhehashadnofurthersymptomsofangina.Whichshouldbethenextinvestigation?

A.BruceprotocolexercisetestB.ModifiedBruceprotocolexercisetestC.RepeatcoronaryangiographytocheckstentpatencyD.DobutaminestressechocardiographyE.Cardiacthalliumscan

Answer:A)Bruceprotocolexercisetest.For public vehicle drivers and heavy goods vehicles driverswhich are classed underGroup2entitlementbytheDVLA,driving isdisqualifiedfor6weeksforMI,CABGandangioplasty.Followingthis,theyhavetoundergoaBruceprotocolexercisetesttostageIIIwithoutsignificantSTchangesoranginalsymptoms.



CardiologyQ112A 45 year oldman hasworsening breathlessness.On examination, he has a systolicbloodpressureof115mmHgwhichdropsto90mmHgduringinspiration.Whichofthefollowingconditionsismostlikelytobepresent?

A.CongestivecardiacfailureB.CardiactamponadeC.AtrialfibrillationD.VentriculartachycardiaE.ICDimplantation

Answer:B)cardiactamponade.Theclinical feature ispulsusparadoxus.This isdefinedasadrop inbloodpressurebymore than20mmHgduring inspiration. It isadefinite signofcardiac tamponade,butmayoccasionallyoccurwithacuteconstrictivepericarditisandCOPD.



CardiologyQ113A50yearoldladyiscurrentlyasymptomaticbutundergoesamedicalexamination.HerECGshowsleftbundlebranchblock.Duringclinicalexamination,whichoneofthesesignsislikelytobefound?

A.TricuspidregurgitationB.SystolicmurmurinthemitralareaC.ThirdheartsoundD.ReversedsplittingofthesecondheartsoundE.Diastolicmurmurinthepulmonaryarea

Answ

Cardiology 2012 Mrcppass

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