Week 7 formative quiz questions

Question 1

Percutaneous coronary stenting improves mortality rates in stable angina.

Answer 1

False – it improves symptoms, but there is no evidence it improves prognosis in stable disease. However, PCI (percutaneous coronary intervention) has a big impact on mortality in acute coronary syndrome.

Question 2

Rheumatic fever is strongly associated with staphylococcal infection.

Answer 2

False – Rheumatic is associated with infection by Group A beta-haemolytic streptococcal infections (such as strep throat).

Question 3

Patients with a recent stroke cannot have thrombolysis for a STEMI.

Answer 3

True – the risk of intracranial bleeding is too high.

Question 4

Myocardial damage is detected by a rise in troponin levels on a blood test.

Answer 4

True – this is one of the standard investigations performed in suspected acute coronary syndromes. Be aware, however, that any state which places stress on the heart (e.g. sepsis, myocarditis, severe tachycardia) can result in a troponin rise, so this is not sufficient to diagnose ACS in isolation.

Question 5

Hypercholesterolaemia can directly cause endothelial damage leading to atheromatous plaque formation.

Answer 5

True – chronically elevated blood cholesterol levels can damage the endothelium by increasing local production of oxygen free radicals.

Question 6

The renin-angiotensin-aldosterone system adjusts blood pressure through sodium and water retention.

Answer 6

True, this is one of the ways that the RAAS controls blood pressure. Activation of the RAAS also produces Angiotensin II, which is a vasoconstrictor.

Question 7

Stage 1 hypertension is defined as a clinic blood pressure of 135/85mmHg or higher.

Answer 7

False – we know that people tend to have higher blood pressure in the doctor’s office (doctor’s appointments are stressful!) than they do at home, and it is the average blood pressure that we are interested in. For that reason, a home ambulatory average blood pressure of 135/85mmHg or higher is termed stage 1 hypertension, while in the clinic it’s an average BP (over several measurements on separate occasions) of 140/90mmHg.

Question 8

Many ischaemic strokes are caused by atherosclerosis of the carotid artery.

Answer 8

True – commonly, atheromatous debris from carotid artery plaques can embolise and travel to the brain, where it becomes lodged in arterial beds and causes ischaemia.

Question 9

Regarding thrombus formation: The lines of Zahn are formed from alternating bands of red blood cells and lipid.

Answer 9

False – they are alternating bands of RBCs and platelets.

Question 10

The term embolisation specifically refers to movement of detached intravascular thrombus to a distant site.

Answer 10

False – emboli can be solid, liquid or gas. The most common embolus in humans is thrombus, however.

Question 11

In normal laminar blood flow, the cellular component of blood travels at the periphery of the vessel.

Answer 11

False – the cells travel down the centre of the vessel in normal laminar flow, and the plasma is in contact with the vessel walls.

Question 12

Ischaemic chest pain (angina) often comes on with exercise as exercise drastically reduces the supply of blood to the cardiac muscle.

Answer 12

False – this is usually a combination of a “supply” and a “demand” issue. As the heart rate and stroke volume increases with exercise, the oxygen demand of the tissue increases as it works harder. Supply is unable to increase to meet this demand, often due to narrowing of the coronary arteries by atheromatous disease, and the tissue becomes ischaemic. There may also be a slight reduce in supply, as the coronary arteries fill during diastole (remember that diastole is reduced as heart rate increases), but this does not cause symptoms in a healthy heart.

Question 13

Statins can be used to help reduce symptoms in stable angina.

Answer 13

False – statins lower cholesterol levels and may slow disease progression in angina and other atheromatous cardiovascular disease, but will not affect symptoms.

Question 14

Thrombolysis is the first-line treatment for a STEMI.

Answer 14

False – mechanical reopening of the blocked artery by percutaneous coronary angioplasty is the firstline management, with the best evidence base. However for remote and rural patients for whom travel time to the nearest PCI centre is too long, thrombolysis can be used as an alternative.

Question 15

Total occlusion of an artery lumen causes reversible ischaemia such as that seen in stable angina.

Answer 15

False – total occlusion of an artery often follows plaque rupture, as this exposes the highly thrombogenic plaque contents to the bloodstream and provokes thrombus formation. It causes non-reversible ischaemia, and can lead to tissue infarction.

Question 16

Blood pressure target in people over 80 should be <135/75mmHg.

Answer 16

False – we tolerate a slightly higher blood pressure in people over 80, as the risks associated with multiple drug treatments including increased risk of falls becomes more of a concern. People over 80 should have a target blood pressure <145/85mmHg.

Question 17

Regarding atheromatous plaque formation: neutrophils migrate into the arterial intima in response to endothelial damage.

Answer 17

False – monocytes do this, where they transform to foamy macrophages.

Question 18

Thromboembolism often causes infarction of tissue.

Answer 18

True – this is a very common consequence of thromboembolism, and is seen in stroke, limb gangrene and gut infarction. Some tissues have good collateral blood supply and are less vulnerable to infarction.

Question 19

Increase in peripheral vascular resistance will lead to a decrease in blood pressure.

Answer 19

False. Blood pressure = Cardiac output x Peripheral Vascular Resistance, so an increase in PVR will increase blood pressure.

Question 20

A fully-developed atheromatous plaque has a protein core.

Answer 20

False – fully developed atheroma have a lipid core, surrounded by a fibrous tissue cap.

Question 21

Thyroid function testing is routine in investigation of angina.

Answer 21

True – thyrotoxicosis is a rare cause of angina. It causes increased metabolic demand due to pathologically elevated thyroid hormone levels.

Question 22

Elevated blood lactate levels are an indication of tissue ischaemia.

Answer 22

True – remember that cells that are deprived of oxygen will undergo anaerobic respiration. Lactate is a product of anaerobic respiration, and can be detected in a blood test. A clinical application of this is that we routinely check lactate levels in patients who have sepsis, as it gives a good indication of how “sick” a person is. Sepsis raises tissue oxygen demand and also limits oxygen delivery due to vasodilation and hypotension.

Question 23

Calcium channel blockers can cause ankle swelling.

Answer 23

True – these drugs are potent vasodilators, and can cause ankle swelling. This is a common reason for stopping therapy with CCBs.

Question 24

Furosemide is an aldosterone receptor antagonist.

Answer 24

False – furosemide is a loop diuretic. Examples of aldosterone receptor antagonists (mineralocorticoid receptor antagonists) are spironolactone and eplerenone.

Question 25

When establishing someone on drug therapy for hypertension, it is preferable to use low doses of several drugs than a maximal dose of one drug.

Answer 25

True. This is called a “stepped” approach and can limit side effects, and some drugs have synergistic effects when used together.

Question 26

ACE inhibitors are less likely to cause a cough as a side effect than Angiotensin Receptor Blockers (ARBs)

Answer 26

False – it is the other way round. ARBs can be useful alternatives to ACEIs in patients who develop a troublesome cough from ACEI use.

Question 27

Regarding atheromatous plaque formation: Platelet-derived growth factor brings about proliferation of intimal smooth muscle cells

Answer 27

True – this is part of the process that forms the fibrous tissue cap over the atheroma lipid core.

Question 28

Blood pressure should fall significantly during sleep.

Answer 28

True. This is called the “nocturnal dip”, and the loss of this is an indicator of poor prognosis in hypertension.

Question 29

Rheumatic fever is virtually the only cause of tricuspid stenosis.

Answer 29

False – it is virtually the only cause of mitral stenosis.

Question 30

Conn’s Syndrome involves overproduction of Aldosterone.

Answer 30

True. This is one of the more common causes of secondary hypertension.

Question 31

Regarding myocardial perfusion imaging: if no radiolabelled tracer is seen in the myocardium during exercise, the myocardium is functioning normally.

Answer 31

False – normal myocardium will take up tracer. An absence indicates compromised blood supply to the myocardium.

Question 32

Heart failure leads to activation of the Renin-Angiotensin-Aldosterone system.

Answer 32

True – reduced cardiac output is registered by the body as reduced circulating volume, and so the salt and water is retained through RAAS activation in an attempt to raise this.

Question 33

Arterial lumina can spontaneously reopen after occlusion by thrombus.

Answer 33

True – the thrombus will shrink and contract with time, and the fibrin will be broken down, leading to the lumen of the vessel reopening (recanalising) somewhat.

Question 34

Blood pressure over 160/100mmHg is termed severe hypertension.

Answer 34

False. Regardless of whether it is from ambulatory home monitoring or in the clinic, this would be termed stage 2 hypertension.

Question 35

Hypertensive emergencies can be managed on oral drugs and reviewed in 24 hours.

Answer 35

False – the difference between a hypertensive emergency and a hypertensive “urgency” is the presence of end-organ damage, such as renal failure, confusion or heart failure. If there is NO end-organ damage, this is a hypertensive urgency, and can be managed with oral drugs and a review in 24 hours. A hypertensive emergency requires admission to hospital and usually IV therapy.

Question 36

The end result of myocardial infarction resolution is healed tissue with full restoration of function.

Answer 36

False – mature myocardial infarctions form dense collagenous scars. Depending on the size and site, these may severely impact cardiac function or may be well-compensated, but the muscular contractility will never be regained.

Question 37

On an ECG, ST-segment depression is a sign of ischaemia.

Answer 37

True – this may appear after exercise during an exercise tolerance test, indicating cardiac ischaemia. ST segment depression may also indicate fixed or ongoing ischaemia, as in a Non-ST-elevation myocardial infarction (NSTEMI)

Question 38

Atheroma development begins with damage to the arterial endothelium.

Answer 38

True – damage to endothelial lining is the first stage of atheroma formation. This results in a chronic inflammatory response as the artery heals. These two stages occur in a cycle and result in the development of atheromatous plaques.

Question 39

Discrepancy in blood pressure between the right and left arm may be a sign of carotid artery stenosis.

Answer 39

False – this is a clinical finding in coarctation of the aorta.

Question 40

In young patients with hypertension, it is more likely that an underlying cause will be found than it is in older patients.

Answer 40

True – the prevalence of hypertension rises with age, and the majority of cases will be essential (i.e. no identifiable underlying cause). Essential hypertension is fairly unusual in young patients (eg under-30s) however, and in these patients it is much more likely that there will be an underlying cause such as renal disease or an endocrine disorder.

Question 41

Beta-blockers improve anginal symptoms by slowing the resting heart rate.

Answer 41

True – this reduces myocardial workload and beta-blockers also have some anti-arrhythmic effect.

Question 42

New blood vessel formation and collagen deposition begins 1-3 days after a myocardial infarction.

Answer 42

False – this occurs 7-10 days post infarction.

Question 43

Premature corneal arcus is a sign of hyperlipidaemia.

Answer 43

True – corneal arcus refers to a pale ring of lipid deposit visible in the peripheral cornea. This is most significant in young patients. It is considered normal in the elderly.

Question 44

Recommended daily limits of trans fat intake is 30g for men and 20g for women.

Answer 44

False – these are the recommendations for saturated fat intake. It is recommended that all adults limit trans fat intake to 5g/day.

Question 45

Ruptured atheromatous abdominal aortic aneurysm is common in the elderly and often asymptomatic.

Answer 45

False – an abdominal aortic aneurysm (AAA) is a relatively common finding in the elderly, but rupture is usually fatal.

Question 46

ACE inhibitors confer a survival benefit in heart failure.

Answer 46

True – ACE inhibitors have been shown to benefit morbidity and mortality in heart failure. They prevent conversion of Angiotensin I to Angiotensin II, thus inhibiting the RAAS and reducing preload and afterload.

Question 47

Ibuprofen can lower blood pressure.

Answer 47

False – ibuprofen is a non-steroidal anti-inflammatory drug (NSAID), and can cause an increase in blood pressure.

Question 48

Rheumatic fever presents with painful arthritis of the small joints.

Answer 48

False. Rheumatic fever is a disease of disordered immunity, and classically presents with inflammation of the heart and joints. This typically affects large joints, such as wrists, elbows, knees and ankles.

Question 49

Myocardial damage resulting from extreme tachycardia would be classed as a Type 2 myocardial infarction.

Answer 49

True. Type 2 MIs occur when there is a mismatch for whatever reason between myocardial oxygen demand and myocardial oxygen supply (eg tachycardia, anaemia, etc), but the ischaemia is NOT caused by atheromatous coronary artery disease.

Question 50

A histological feature of rheumatic fever is the Aschoff body.

Answer 50

True – this is seen in acute rheumatic fever in the heart. It refers to a focus of chronic inflammatory cells, necrosis and activated macrophages.

Question 51

A patient who has anginal symptoms on climbing one flight of stairs would be classed as having a score of III on the Canadian classification of angina severity.

Answer 51

True – these patients have marked limitations, with symptoms on walking one or two blocks, or climbing a single flight of stairs.

Question 52

Nifedipine MR (a calcium-channel blocker) is safe for use during pregnancy.

Answer 52

True – this is one of the antihypertensive drugs that is recommended for use during pregnancy.

Question 53

Arteriosclerosis is the formation of focal elevated lesions in the intima of large and medium-sized arteries.

Answer 53

False – this describes atherosclerosis. Careful, because the words sound very similar! Arteriosclerosis is an age-related change that involves the thickening of smooth muscle, intimal fibrosis and duplication of internal elastic laminal layer – all of which also cause luminal narrowing.

Question 54

Elderly people have high levels of renin, which often is the main driver of hypertension in this age group.

Answer 54

False – older people have lower renin levels, therefore using ACE inhibitors (drugs which block the conversion of Angiotensin I to Angiotensin II) is less likely to be effective, and they are not the firstline treatment choice in this age group.

Question 55

Acute myocardial infarcts are classified depending on whether there is elevation of the PR segment on the ECG.

Answer 55

False – MIs are classified based on the presence or absence of elevation of the ST segment.

Question 56

ST segment elevation on an ECG results from complete occlusion of a coronary artery.

Answer 56

True. These acute coronary syndromes have a high mortality (especially untreated!) and are associated with transmural infarction.

Question 57

ACE inhibitors should not be given to pregnant patients or patients intending to become pregnant.

Answer 57

True – ACE inhibitors can have adverse effects on the development of the foetal renal system, and are contraindicated in pregnancy.

Question 58

Rheumatic fever can cause heart murmurs.

Answer 58

True – rheumatic fever causes inflammation of the heart, and this includes the endocardium, of which the valves are part. Inflammation of the valves can result in valve stenosis, regurgitation, or vegetations, all of which may be clinically detected as murmurs.

Question 59

Generally the more of the artery lumen a plaque occludes, the more prone to rupture it is.

Answer 59

False – highly stenotic (i.e. plaques that occlude a large proportion of the lumen) plaques often have a thick fibrous cap, and are less vulnerable to rupture.

Question 60

The most common form of thromboembolic disease originates from arteries in the legs.

Answer 60

False – the most common source of thromboembolism originates in the deep venous system of the legs. This can travel up the vena cava to the right side of the heart, and then into the pulmonary artery, where it becomes a pulmonary embolism.