Cardio Practice Qs Flashcards

Question

Which of the following may show ST-segment elevation on an ECG? a) Unstable angina b) Pritzmetal angina c) Cardiomyopathy d) Stable angina e) NSTEMI

Answer 1

B. Pritzmetal angina Prinzmetal angina may show ST elevation on an ECG along with STEMI and pericarditis. * Unstable angina would often be normal or can show ST depression and flat T waves. * Stable angina will show no changes. * NSTEMI will show ST depression, deep T wave inversion and pathological Q waves.

Answer 2

C. B-type natriuretic peptide (BNP or NT- proBNP) The presentation is typical of heart failure and therefore NT-proBNP would be the most appropriate blood test. BNP is released from the heart (mainly ventricles) in response to stretch, it is a marker for HF. * U&E are useful but are not diagnostic in this instance. 8 HbA1c looks at glycated Hb over the last 120 days * Blood cultures would be indicated if infection was suspected. * ANP is released mainly from the atria in response to stretch.

Answer 3

A. Valsalvar manoeuvre The patient in the question has a supra-ventricular tachycardia. SVT are a form of narrow complex tachycardia and therefore the as the patient is young, the first line in this case would be valsalva manoeuvre which is where the nose and mouth is held during forceful expiration to stimulate the vagus nerve to return the heart into sinus rhythm. * Amiodarone would be used in a broad-complex tachycardia. * Atropine and adrenaline would be used during an episode of bradycardia to speed the heart up. * DC cardioversion would not be first line in this management.

Answer 4

C. CHA2DS2-VASc Screening tools such as ABCD2, QRISK3 and FRAX are common topic to come up in exams. Knowing which tools do what is more important than knowing each factor that is used to calculate a score. The CHA2-DS2-VASc or just CHADS2 score both estimate stroke risk in patients with AF. *ABCD2 – estimates risk of stroke after a suspected TIA. *HAS-BLED – estimates risk of bleeding on patients on anticoagulation *QRISK3 – estimates risk of developing a heart attack or stroke in next 10 years. *Well’s criteria – estimates risk of Pulmonary Embolism in clinical presentation.

Answer 5

B. B-Natriuretic peptide This patient has a likely diagnosis of with key factors such as shortness of breath on exertion, paroxysmal nocturnal dyspnoea, and peripheral oedema. An ECG, echocardiogram and CXR are all good investigations, but you should remember a BNP or NT- proBNP as the first line investigation, especially in primary care.

Answer 6

a) Mitral regurgitation - aortic stenosis which causes an ejection-systolic murmur - and mitral regurgitation which causes a pan-systolic murmur - aortic regurgitation which causes an early diastolic murmur - mitral stenosis which causes a mid-diastolic murmur.

Answer 7

A) Amlodipine Getting familiar with the NICE guidelines is important for your 2a exams. Hypertension medical management is a common topic, because of how common hypertension is and the slight complexity with two different patient groups. If a patient is under 55 or has type 2 diabetes an ACEi or ARB should be started. If a patient is black or over 55 then a CCB such as amlodipine should be started.

Answer 8

C) Echocardiogram - Aortic stenosis is the obstruction of blood flow across the aortic valve due to aortic calcification; presents with SoB with exertion, angina, or syncope. Characteristic murmur is systolic mid to late peaking with a crescendo-decrescendo pattern, radiation to the carotids. Doppler echo is essential for diagnosis and will show a pressure gradient across the stenotic aortic valve. Valve replacement is the treatment. * CXR is unlikely to reveal much, calcification may be visible in larger arteries. LV hypertrophy may occur due to increased pressure required to pump blood through aortic valve. * ECG is used in the diagnosis of aortic stenosis. Demonstrates LV hypertrophy and absent Q waves, AV block, BBB. In AS patients 90% of the ECGs recorded show some abnormality. * Trans-thoracic echo (including Doppler) is the best test for the initial diagnosis and subsequent evaluation of AS. The sensitivity and specificity of the test are high. Elevated aortic pressure gradient; measurement of valve area and LV ejection fraction. * Exercise tolerance test is and ECG that is recorded whilst you are exercising. Used to test for coronary heart disease and angina. * Auscultation is one method of detecting heart murmurs but is not the most appropriate diagnostic investigation.

Answer 9

C) Adrenaline The resuscitation council’s algorithm for anaphylaxis says: 1. ABCDE 2. Check for obvious potential diagnosis 3. Call for help 4. Adrenaline 5. Establish airway / high flow O2 / IV fluid challenge / chlorphenamine / hydrocortisone Adrenaline is the first medication to be given, opens airway and blood vessels helping to reverse the effects of anaphylaxis. 500 micrograms (0.5 mL) of 1:1000 IM. * Chlorpheniramine is an antihistamine which takes 15-20 mins to work. * Histamine release is the cause of anaphylaxis so this helps reverse the effects. * Hydrocortisone is a corticosteroid, its benefit in anaphylaxis is still unproven but aims to stop a biphasic reaction, reduce the symptom reoccurrence, and wheezing. * Intravenous fluids are given as large volumes of fluid may leak from the patient’s circulation. Signs of shock, vasodilation and a low BP. * Salbutamol is a beta 2 adrenergic agonist which causes bronchodilation helping the patient to breathe during anaphylaxis.

Answer 10

A) Pericarditis Pericarditis – this is inflammation of the membrane that surrounds the heart, movement of the heart causes pain. It causes pleuritic pain which is classically sharp and worse on inspiration. Pericarditis pain is relieved when leaning forward. It can occur after a CABG as the tissue has been damaged, another cause is Dressler Syndrome whereby pericarditis occurs as a complication of an MI 2-3 weeks afterwards. They may have a fever, this is not present in this description * Endocarditis – inflammation of heart valves typically caused by staph or streptococci. History is usually IV drug user or previous dental surgery. The tricuspid valve as this is the first valve blood passes from the systemic circulation so is affected after systemic infection. The patient will have a fever, murmur over the affected valve, numerous signs on examination – roth spots, splinter haemorrhages, Janeway lesions, Osler’s nodes. * Myocardial infarction – pain wouldn’t typically change depending on position, though it does radiate to the left shoulder which is typical. This option can be ruled out as the troponin blood test that detects recent MIs is negative. * Aortic dissection – separation of the media lamina resulting in blood entering the wall of the aorta. Presentation is classically acute chest pain radiating to the back between the scapulae. Physical examination will show unequal blood pressure in arms.

Answer 11

E) Unstable angina Unstable angina is incomplete coronary artery occlusion usually by a thrombus, atherosclerotic plaque has ruptured which causes a clot to form and occlude the artery. The pain now occurs at rest and worsens on exercise. ST segment depressions and T wave inversions. No elevation of biomarkers. * Stable angina is typically secondary to atherosclerosis partially occluding the coronary artery. Pain occurs on exercise when O2 demand is higher. This is relieved with nitrates and rest. May show ST depressions. * STEMI – full width infarction of the myocardial tissue caused by occlusion of a coronary artery. ST elevation, peaked T waves, Q waves. Biomarkers are positive. * NSTEMI – partial infarction of the myocardial tissue caused by occlusion of a coronary artery. ST depression and T wave inversion. Biomarkers are positive. Prinzmetal angina is a spasm in the coronary artery, it shows a dramatic ST elevation during episodes. Relieved with nitrates. Occurs unrelated to activity levels.

Answer 12

C. Infective Endocarditis is correct - there are risk factors of prosthetic valves and IV drug use, alongside splinter haemorrhages and Osler’s nodes. A. Pericarditis typically presents with a history of a viral infection, with acute onset chest pain that is characteristically relieved by leaning forward. B. SLE can present with splinter haemorrhages, but Osler’s nodes are not characteristic D. Rheumatic heart disease does present with subcutaneous nodules, but also alongside arthritis, chorea and a specific skin rash. It tends to present in children/younger adults. E.HSP typically presents with a red/purple rash up the back of the legs and buttocks.

Answer 13

E. Accumulation of a large amount of fluid in the pericardial cavity that compresses the heart and reduces cardiac function - This is the correct definition of cardiac tamponade. A. This is the definition of Pulsus Paradoxus, which is a sign of cardiac tamponade B. This is the definition of Pericardial Effusion - basically a less extreme version of cardiac tamponade C. This is the definition of Kussmaul’s sign, which is a sign of cardiac tamponade D. This is the definition of constrictive pericarditis, which can only be distinguished from cardiac tamponade by cardiac catheterisation (present the same clinically as they both restrict filling of the heart)

Answer 14

B. The four features of the tetralogy of Fallot are an overriding aorta, VSD, pulmonary artery stenosis and right ventricular hypertrophy. RV hypertrophy occurs in response to pulmonary artery stenosis, to try and maintain cardiac output. This means there is a right to left shunt through the VSD, resulting in cyanosis due to deoxygenated blood entering the oxygenated circulation. Left ventricular hypertrophy is not a feature.

Answer 15

A. Ascites is a feature of right-sided heart failure, as it causes congestion in the systemic system, resulting in accumulation of fluid * B. You would expect dyspnoea (difficulty breathing) in left-sided heart failure, as it causes pulmonary congestion * C. A reduced ejection fraction occurs when the systolic function of the LV is reduced, meaning the volume of blood pumped out of the heart is less than the volume of blood that enters the LV during diastole. There isn’t always a reduced ejection fraction in left-sided heart failure, as the cause may be diastolic, meaning the volume moving in and out of the heart would be the same. * D. Orthopnoea (difficulty breathing when lying down) is a classic symptom of heart failure. The severity can be measured by asking the patient how many pillows they use to sleep with. * E. JVP may be raised in right-sided heart failure, as it occurs when there is systemic congestion, due to raised venous pressure. It is not raised in left-sided heart failure.

Answer 16

C. Brain Natriuretic Peptide (BNP), which is released from the ventricles BNP is released by the ventricles in response to overstretching of the walls of the heart (i.e. when heart failure leads to fluid overload). Raised levels support a diagnosis of heart failure, and normal/low levels exclude heart failure as a diagnosis. ANP is released by the atria, but this is not measured in the diagnosis of heart failure.

Answer 17

D. NSTEMI - this is correct, as chest pain radiating to the left shoulder with dyspnoea are classic symptoms of an MI. This is confirmed with the ECG, which shows ST depression. A. Stable angina only occurs on exertion, and improves when the person stops exerting themselves, unlike in this case. B. The clinical features align with a diagnosis of a STEMI, however this is excluded due to ST depression on the ECG, and a STEMI has ST elevation C. Decubitus angina is a type of angina that occurs when the person lies down E. Unstable angina is an onset of chest pain at rest, but you would not expect other features such as going pale or the pain radiating to the shoulder. A more classic presentation would be someone who used to get chest pain on exertion who is starting to get episodes of pain when they are sitting still, rather than such an acute presentation.

Answer 18

C. Pyelonephritis leading to urosepsis, Urosepsis can lead to septic shock, but this is not a cause of hypovolaemic shock as there is no blood/fluid loss A. A ruptured aortic aneurysm has a mortality rate of 80% due to the rapid onset of hypovolaemic shock from internal blood loss B. Severe burns result in loss of fluid, meaning the circulating volume is depleted D. Hypovolaemic shock is caused by anything that results in a depleted circulating volume, therefore vomiting is a possible cause as it can lead to dehydration E. Bleeding from the leg will reduce circulating volume so can cause hypovolaemia

Answer 19

E. Right Coronary Artery The Right Coronary Artery supplies the inferior surface of the heart, which corresponds to leads II, III and aVF. Leads I, v5, v6 and aVL = Lateral = Circumflex Leads v3 and v4 = Anterior = LAD

Answer 20

B. CHAD2DS2-Vasc score CHAD2DS2-Vasc score is used to calculate the risk of having a stroke in patients with atrial fibrillation. * HAS-BLED score (E) calculates the risk of having a major bleed within 1 year in patients with atrial fibrillation. * Wells score (A) is used to calculate the risk of venous thromboembolism. * FRAX score (C) is used to calculate the risk of having a fracture within the next 10 years. * ABCD2 score (D) is used to calculate the risk of having a stroke after a TIA.

Answer 21

C. Mobitz type 1 second-degree heart block The most likely diagnosis is Mobitz type 1 second-degree heart block (C). This is due to the increasingly long PR intervals and drop in QRS complexes, giving a characteristic Wenckebach pattern. * Mobitz type 2 (D) presents similarly with a drop in QRS complexes, but the PR intervals remain a constant length. * Third-degree heart block (E) presents with no association between atrial and ventricular contraction.

Answer 22

A. Aortic dissection This stem gives a classic history of Aortic dissection. * An Anterior Myocardial Infarction typically causes a crushing central chest pain radiating to the neck/left arm not typically down the body. * Angina is typically associated with pain on exertion and relieved by rest. * The pain in Costochondritis is typically an achy pain felt towards the front of the chest. * Gastroesophageal reflux is typically a retrosternal burning chest pain often related to meals, lying down or straining.

Answer 23

A. Delta wave a Delta wave is caused by the accessory conduction pathway in WPW. * Increased PR interval is wrong as the PR interval should decrease in WPW. * Convex ST elevation indicates infarction. * Saddle ST elevation indicates pericarditis. * Bifid p wave indicates left martial enlargement.

Answer 24

B. Ejection systolic murmur ]given the typical Aortic stenosis history an Ejection systolic murmur is most likely. * Pansystolic murmur would indicate mitral regurgitation. * Parasternal heaves, although a possible sign in aortic stenosis this sign is picked up on palpation and auscultation. * A Rumbling mid diastolic murmur indicates Mitral stenosis. * A Constant machinery murmur indicates a patent ductus arteriosus.

Answer 25

A- this is the Ductus arteriosus being described, the remnant of this is the Ligamentum arteriosum in adults. * The Ductus venosus allows blood to bypass the liver, the remnant of which is the Ligamentum venosum in adults. * The umbilical arteries, found in the abdominal and pelvic regions, supply deoxygenated blood from the fetus to the placenta.

Answer 26

B. Dressler's syndrome develops 2 to 10 weeks post MI. It is thought that myocardial injury stimulates the formation of antibodies against the heart muscle. Classic symptoms include fever, chest pain and plural pain with a pericardial rub. Treatment involves aspirin, NSAID or steroids.

Answer 27

C- Dilated prominent upper lobe vessels are seen in heart failure not lower lobe vessels. The ABCDE mnemonic can help remember the x-ray findings in heart failure. Alveolar oedema, Kerley B lines (Interstitial oedema) Cardiomegaly, Dilated prominent upper lobe vessels and Pleural effusion

Answer 28

D. Roth spots (retinal haemorrhage with pale centers) are the only sign in the eye in this list the rest are signs that would be found on the hand. Although Hederden’s nodes are seen on the hands, these are seen in Osteoarthritis not endocarditis (Osler's nodes are seen in endocarditis).

Answer 29

A. Age is the only unmodifiable risk factor, the rest can all be modified.

Answer 30

A. The symptoms in this history point towards Left sided heart failure. Right sided heart failure, although would have fatigue. signs of RHF differ and include a raised JVP, pitting edema and ascites. A Pneumothorax would present typically with sudden onset SOB or pain. Pneumonia, although SOB would be present the sputum would be green/yellow. Pericarditis is also less likely with this history.

Answer 31

A. is an example or secondary prevention. Methods to detect and address an existing disease prior to the appearance of symptoms. C and E are examples of primary prevention and D is a possible treatment for a MI.

Answer 32

E. NICE recommend CT coronary angiography (E) as the first-line investigation in patients with symptoms typical for stable angina. Invasive coronary angiography (A) is reserved for if other sipler investigations are inconclusive. A resting 12-lead ECG (B) can show signs of previous ischaemia but cannot diagnose stable angina in itself. Myocardial perfusion scintigraphy (C) is used to evaluate the functionality of the heart and is reserved for later-line. A resting transthoracic echocardiogram (D), although useful, will not diagnose stable angina in itself.

Answer 33

A. First line treatment for angina is a beta-blocker, such as bisoprolol, or a cardioselective calcium channel blocker, such as verapamil or diltiazem. If these do not work by themselves, NICE recommend combining beta blockers with a non-cardioselective calcium channel blocker, such as nifedipine (A). Combining a beta blocker with a cardioselective calcium channel blocker such as verapamil (B) is contraindicated due to a risk of asystole. Aspirin (C) is used to reduce the risk of myocardial infarctions as secondary prevention. Atorvastatin (D) is used to lower plasma cholesterol, not to prevent further angina attacks directly. GTN (E) is used for symptomatic treatment of stable angina attacks and does not prevent them.

Answer 34

B. This patient is having a STEMI, and has presented within 12 hours. The most appropriate initial treatment here is dual antiplatelets (aspirin + prasugrel/ ticagrelor/ clopidogrel), alongside anticoagulation (unfractionated heparin) and PCI (B). Fondaparinux, ticagrelor and fibrinolysis (A) are used if PCI cannot be done within 2 hours of presentation to hospital, but is not as good as (B). (C) is the long-term drug management post-MI. (D) describes the initial treatment for an NSTEMI or unstable angina. CABG (E) is not typically performed for STEMIs and is used more for stable angina.

Answer 35

D. This patient has left ventricular systolic failure. (D) is the only sign consistent with this, as fluid will back up from the poor left ventricle into the lungs. The other signs (A, B, C, E) are all signs more typical of right ventricular failure as fluid backs up from the RV into the peripheries.

Answer 36

B. Spironolactone (B) is recommended as the next treatment to add after an ACE-I and beta blocker in heart failure with reduced ejection fraction and improves mortality. The other drugs (A, C, D and E) can be added but are after spironolactone, normally by a specialist.

Answer 37

C. This question is asking about secondary causes of hypertension. He likely has Cushing’s syndrome (C) due to the clinical features - abdominal obesity and striae, and a history of poorly controlled IBD which has likely needed multiple courses of steroids. Essential hypertension (A) is less common in someone this age. There is nothing in the history to suggest Conn’s syndrome (B), ADPKD (D) or coarctation of the aorta (E), although these are all causes of secondary hypertension.

Answer 38

E. NICE recommend that in people with type 2 diabetes of any age, an ACE-I (E) is first-line for hypertension. Indapamide (A) is a thiazide-like diuretic, which can be added 2nd line. Amlodipine (B) is a calcium channel blocker which can be used first-line in Afro-Carribean people or those aged 55+ who don’t have type 2 diabetes. Spironolactone (C) is used later down the line if the above treatments have not worked. Bendroflumethiazide (D) is a thiazide diuretic, not currently used for hypertension - only ‘thiazide-like’ diuretics are on the NICE pathway.

Answer 39

A. He has an ejection systolic murmur radiating to the carotids and therefore probably has aortic stenosis. The most common cause of this is senile calcification of the valve (A). A bicuspid aortic valve (B) is commoner in people under 60 years old. Rheumatic fever (C) is rare in the West and there is nothing in the history to suggest this. Aortic stenosis being caused by endocarditis (D) or carcinoid syndrome (E) is highly unlikely.

Answer 40

B. The ECG describes atrial fibrillation. Patients who warrant anticoagulation to prevent strokes are normally given a personal choice between a DOAC e.g. apixaban (A) or warfarin (B). Warfarin is correct here as the patient has a metal heart valve and DOACs are not as good as warfarin here. LMWH (C) could be used in the short-term if someone needed anticoagulation acutely in hospital, but the patient’s old ECG shows AF. Aspirin (D) and clopidogrel (E) are not used to prevent strokes in AF as the blood pooling in the atria has more venous properties, so anticoagulants are used rather than antiplatelets.

Answer 41

C. The symptoms and ECG point to pericarditis. The treatment of this is NSAIDs and colchicine (C). Paracetamol (A) would not be used to treat the pericarditis itself. Ibuprofen alone (B) used to be used for pericarditis but the addition of colchicine is beneficial. PCI (D) has no place here. Steroids like prednisolone (E) can be used in pericarditis but normally only if there is an autoimmune cause as it can give people more recurrences.

Answer 42

Chest pain that radiates (1) Relieved with rest or GTN spray (1) Provoked by physical exertion (1)

Answer 43

Modifiable: Smoking, Diabetes, Cholesterol/HDL ratio, Blood Pressure, BMI Non-Modifiable: Age, Gender, Ethnicity, Angina/MI 1st degree relative, Diagnosis of: AF, RA, SLE, ED, Sever mental illness,

Answer 44

Example: Ramipril, Lisinopril, Enalapril SE: Dry Cough, Hyperkalaemia, Fatigue, Headache

Answer 45

Hours = Tall T waves, ST Elevation. Days = T inversion, Pathological Q waves

Answer 46

- Shortness of breath - Fatigue - Peripheral oedema

Answer 47

- Alveolar oedema (bat wings) - Kerley B lines (interstitial oedema), - Cardiomegaly, - Dilated Prominent Upper Lobe Vessels, - Pleural Effusion

Answer 48

- A large, misaligned ventricular septal defect - An overriding aorta - Right ventricular outflow tract obstruction - Right ventricular hypertrophy

Answer 49

Pericarditis

Answer 50

Calcium Channel Blocker (e.g. amlodipine)

Answer 51

Atrial fibrillation

Answer 52

- Sudden ‘tearing’ chest pain +/- radiates to back - Unequal arm pulses and BP - Acute limb ischaemia - Paraplegia - Anuria

Answer 53

- Stage I: asymptomatic - Stage II: intermittent claudication - Stage III: rest pain/nocturnal pain - Stage IV: necrosis/gangrene

Answer 54

Renal Disease e.g CKD, renal artery stenosis, polycystic kidney disease, Cushing’s, Conn’s, Phaeochromocytoma, Coarctation of aorta, Pregnancy, COCP

Answer 55

Anaphylactic, Cardiogenic, Septic, Haemorrhagic, Neurogenic

Answer 56

Rupture, Thrombosis, Embolism, Excess pressure on other structures

Answer 57

B – Aspirin and Ticagrelor Patients with MI require dual antiplatelet therapy consisting of aspirin and a PY12 inhibitor (e.g clopidogrel, ticagrelor or prasugrel). Note that warfarin (D) and dalteparin (E) are not antiplatelet therapies, they prevent venous clotting and hence are often prescribed in situations such as DVT, PE or AF. Acute Coronary Syndromes suggests immediate management of STEMI involves: use of GTN spray, administer O2 (only if hypoxaemic, pulmonary oedema or continuing myocardial ischaemia) analgesia- (e.g morphine and a co-prescribed antiemetic), dual antiplatelet therapy (aspirin and clopidogrel/ticagrelor), restore patency to occluded artery (PCI or thrombolytic drug).

Answer 58

A – Inhibition of aldosterone receptor in the distal tubules (B) inhibition of cyclooxygenase enzymes in proximal tubules= COX inhibitor e.g Aspirin. (C) Inhibition of L-type voltage gated calcium channel in the nephron= calcium channel blocker e.g Amlodipine. (D) inhibition of the sodium chloride transporter in the distal convoluted tubule= thiazide-like diuretic e.g Bendroflumethiazide. (E)Inhibition of the sodium/potassium/chloride symporter in the loop of Henle= loop diuretics e.g furosemide.

Answer 59

A- Caucasian race High caffeine consumption, sedentary lifestyle, smoking and type A personality are all associated with an increased risk of developing hypertension. Note that from the hypertension management guidelines afro-Caribbean race carries an increased risk of hypertension (<55/Afro-Caribbean = ACEi first line).

Answer 60

D – Mitral regurgitation Aortic stenosis would present with syncope and angina, and on auscultation an ejection systolic murmur would be heard. Aortic regurgitation would present with symptoms to similar symptoms as aortic stenosis, with an early diastolic/Austin Flint murmur heard on auscultation. Mitral stenosis would present with similar symptoms to mitral regurgitation, but with a diastolic murmur on auscultation. Tricuspid regurgitation may present with signs of right-sided heart failure, this pansystolic murmur is not heard at the apex but at the left lower sternal edge.

Answer 61

C – ST depression Myocardial infarction ECG changes include: ST elevation, ST depression (C), T wave inversion, abnormal Q wave. Absent P waves (A) are typically seen in SVT, atrial fibrillation, atrial flutter. Tall tented T waves (D) are characteristic of hyperkalaemia. QT prolongation (B) can be a side effect of medications e.g amiodarone and certain antibiotics. (E) Wide QRS complexes are typically seen in patients with bundle branch blocks.

Answer 62

E – Ramipril A blood pressure over 135/85 recorded by ambulatory BP monitoring requires pharmacological management therefore (C) lifestyle changes only is incorrect. John is caucassian and under 55 so first line is an ACE inhibitor such as ramipril (E). If John was Afro- Caribbean or over 55 he would be started on a calcium channel blocker like amlodipine (A). If John was intolerant to ramipril he could be started on an angiotensin receptor blocker such as losartan (D). If John’s BP did not respond to treatment with an ACE inhibitor or ARB he could be started on a thiazide-like diuretic, for example Bendroflumethiazide (B).

Answer 63

A – Atrial fibrillation This patient has the classical symptoms of a stroke. AF (A) increases the risk of stroke due to blood collecting in the atria and forming clots. Cor pulmonale (B) is right sided heart failure and presents with shortness of breath. Myocardial infarction (E) would most commonly present with symptoms like chest pain, nausea, and sweating. Left bundle branch block (D) is normally asymptomatic and is diagnosed by ECG changes. Infective endocarditis (C) can cause stroke however, it is much rarer than AF and you would expect other indications in the history of IE such as fever, new murmur, Janeway lesions, Osler’s nodes, splinter haemorrhages etc.

Answer 64

B – QRISK2 score ABCD2 is used to determine stroke risk after a TIA. CHA2DS2-VASc is used to calculate stroke risk in patients with AF. COVID19 is not a score. Wells score is used to determine the risk of DVT or PE (note, different wells scores respectively).

Answer 65

B Statins reduce the risk of heart attack therefore it is to be expected that in the trial a smaller percentage of heart attacks to occur in the statin group compared to the placebo group. (B) describes the relative risk reduction (1.65/2.67x100 =61.%) whereas (A) describes the absolute risk reduction (2.67-1.65=1.02). (C) is describing the number needed to treat (NNT) of statins. D is describing the number needed to harm (NNH) of placebo. E is describing the concept of a 95% confidence interval.

Answer 66

D correctly describes the route of electrical conduction through the heart.

Answer 67

E- Family History The CHADS VASc score is used to calculate the stroke risk and subsequently anticoagulation need in patients with Atrial Fibrillation. CHADS-VASc stands for Congestive Heart Failure // Hypertension // Age (75+=2) // Diabetes Stroke/ TIA/ Thromboembolism Vascular disease // Age (65-74) // Sex category (female=1)

Answer 68

C- Irregularly Irregular (A)Absent= asystole/death (B)Collapsing= aortic regurgitation, (C) Irregularly irregular= atrial fibrillation. (D) Pulsus paradox= BP drops significantly during inspiration, seen in severe Asthma, COPD, blood loss and cardiac conditions. (E) Radio-radial delay= pulse is significantly stronger in one arm than the other and is seen in coarctation of the aorta.

Answer 69

B- Aortic Stenosis is the correct answer as it produces an ejection systolic crescendo decrescendo murmur (and a slow rising, narrow pulse pressure), heard loudest on expiration. (A)Aortic regurgitation produces an early diastolic decrescendo murmur (and a collapsing pulse) (C) Mitral regurgitation produces an apical pansystolic murmur. (D) Mitral stenosis produces an apical mid diastolic rumble. (E) Pulmonary stenosis produces an ejection systolic murmur heard loudest on inspiration.

Answer 70

E- Shortness of breath, fatigue, ankle oedema The three cardinal signs of heart failure are shortness of breath, fatigue and ankle oedema. Patients often experience orthopnoea (dyspnoea when lying flat) and also paroxysmal episodic nocturnal breathing (stopping breathing in your sleep). Other signs include cold peripheries, raised JVP, hypotension, cyanosis, oedema and increased weight. On examination patients can have 3rd and 4th heart sounds, displaced apex beat, murmurs and bibasal crackles.

Answer 71

A - Amlodipine prescription The first line treatment for a patient with hypertension who is over 55 or is of afrocarribean descent is a calcium channel blocker. Amlodipine is an example of this. If the man was under 55, he should be considered for an ACE inhibitor such as ramipril or an ARB (angiotensin receptor blocker) such as Candesartan.

Answer 72

B- R wave in V1 and Slurred S wave in V6 R wave resembles an M // Slurred S wave resembled a W. Use the acronyms MARROW and WILLIAM to help you remember which is which. * MARROW ‘RR’= Right bundle branch block. The first letter is M so lead 1 has a complex resembling an M (R wave) and the 6th letter is W so lead 6 has a complex resembling a W (Slurred S wave). * WILLIAM ‘LL’= Left Bundle Branch Block. The first letter is W so lead 1 has a complex resembling a W (Slurred S wave) and as the 6th letter is M lead 6 has a complex resembling an M (R wave). This is the opposite of RBBB.

Answer 73

E- Pink The ‘6 Ps of critical limb ischaemia’ are: Pain, Pallor, Paralysis, Paralysis, Paraesthesia, Perishingly cold and pulselessness. The limb would be pale not pink.

Answer 74

A- Atrial Septal Defect The 4 key features of tetralogy of fallow are ventricular septal defect, pulmonary stenosis, hypertrophy of the right ventricle and overriding aorta. I find it helpful to think of the VSD overloading the already narrow/stenosed pulmonary outflow track and this is why you get the hypertrophy of the right ventricle.

Answer 75

C- 145/95 Clinic Readings: Stage 1= >140/90. Stage 2= >160/100. Severe HTN= >180/110 Ambulatory readings (C) 145/95= Stage 1 HTN. (D) 165/105 =Stage 2 HTN. (E) 180/110= Severe HTN

Answer 76

E- Xanthelasma are cholesterol deposits around the eyes. Distinctive signs of infective endocarditis are splinter haemorrhages, Osler’s nodes, Janeway lesions, Roth spots and fever.

Answer 77

(B)- Fibrinolysis with IV Tenecteplase performed within 12 hours of STEMI onset if patients cannot get PCI done (PCI must be done within 2 hours of onset and our patient presents to A&E after 4 hours) (A)- CTPA is diagnostic investigation for suspected PE, performed in patients with Wells Score>4. (C)- High flow oxygen is only indicated in patients with STEMI that are hypoxic, our patient has sats of 97% OA. (D)- PCI is first line treatment for STEMI if it can be performed within 2 hours of onset, otherwise it is fibrinolysis with IV Tenecteplase (E)- The patients observations show they are afebrile, infective cause is unlikely in this scenario and hence broad-spectrum antibiotics are not indicated.

Answer 78

C- NT-proBNP (BNP) levels. NICE guidelines recommend NT-proBNP for diagnosing heart failure. (A) CXR shows signs of heart failure (ABCDE) but is not diagnostic and not first line (B) CT scan wouldn’t be first line investigation for heart failure. (D) ECG can show changes but not diagnostic. (E) Echocardiogram is gold standard but not a first line investigation.

Answer 79

C- Ramipril - ACEi is first line treatment based on this patients’ demographics. This patient has stage 1 hypertension. (stage 1. ≥140/90 mm Hg, stage 2. ≥160/100, stage 3. ≥180 systolic or 120 diastolic.) (A) Bisoprolol is a beta-blocker, a rate limiting drug not used as first line treatment for HTN. (B) Furosemide is a loop diuretic not used for the treatment of HTN, thiazide like diuretics such as Bendroflumethiazide are second line options. (D) Amlodipine is a dihydropyridine calcium-channel blocker first line for >55yrs or of Afro-Caribbean ethnicity. (E) Nifedipine is a dihydropyridine calcium-channel blocker first line for >55yrs or of Afro-Caribbean ethnicity.

Answer 80

E- Aortic Stenosis - An ejection-systolic murmur is characteristic for aortic stenosis. (A) Patients with HF will only present with a murmur if there is also valvular disease, however there can be a gallop rhythm due to the presence of S3. (B) An early diastolic murmur is characteristic for aortic regurgitation (C) A pansystolic murmur is characteristic for mitral regurgitation. (D) A rumbling mid-diastolic murmur is characteristic for mitral stenosis.

Answer 81

C- Dilated Bronchioles Chest Xray signs for heart failure are ABCDE (Alveolar oedema, Kerley B lines (interstitial oedema), Cardiomegaly, Dilated upper lobe vessels, pleural Effusion). Therefore C- dilated bronchioles is incorrect.

Answer 82

B- QRisk3= 10-year probability of CV event. (A) Cha2Ds2-VaSc= risk of stroke in AF. (C) ABCD2= risk of stroke after TIA. (D) Wells score= risk of DVT. (E) Modified Duke Criteria= Infective endocarditis criteria.

Answer 83

D- Ramipril Most common side of effect of ACEi (ramipril) is a dry cough due to increased levels of bradykinin. It is unlikely to be infective exacerbation of asthma / pneumonia given all observations and examinations are normal- these cases would likely be abnormal; you would expect at least patient to be pyrexical. Unlikely to be lung cancer due to lack of other symptoms (weight loss, SOB etc). Metformin does not cause dry cough.

Answer 84

A- Echocardiogram is the gold standard for diagnosing valvular disease. (B) ECG may show arrhythmias but not diagnostic. (C) Troponin- T I used to aid diagnosis of Acute Coronary Syndromes (ACS). (D) NT-proBNP levels used to diagnose heart failure. (E) CXR doesn’t diagnose valvular disease but may show LA enlargement.

Answer 85

B- Absent P waves, narrow QRS + irregularly irregular ventricular rhythm are all ECG changes associated with AF. (A) Sawtooth flutter waves= seen in atrial flutter. (C) Delta waves= Wolff-Parkinson-White syndrome. (D) Saddle-shaped ST segment elevation= acute pericarditis. (E) ST segment depression= sometimes seen in myocardial ischaemia.

Answer 86

E- Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy is most likely given that he’s young and has a +ve family history of young cardiac death. Other diagnoses are unlikely due to his young age.

Answer 87

E- Prescribe Ramipril in addition to Amlodipine Hypertension management: patients under 55 should be started on ACEi/ARB, patients over 55 (like in this case- age 58) or afrocarribbean should be started on CCB. If hypertension persists then the 2nd line treatment is to combine the ACEi/ARB and the CCB. If hypertension persists add Thiazide-like diuretic. Therefore answer is (E) prescribe ramipril in addition to amlodipine. Percutaneous Coronary Intervention (A) is used for the management of MI not HTN. Atenolol (B) is a beta blocker, rate-control drug with limited use in HTN management. Adding Candesartan and removing amlodipine is not appropriate as we need to combine ACEi/ARB and CCB for 2nd line not switch to the other. Prescribing Bendroflumethiazide (D) is the third line management not 2nd. ACEi example= Ramipril. ARB example= Candesartan. CCB example= Amlodipine. Thiazide-like diuretic example= Bendroflumethiazide.

Answer 88

E- U waves The presentation described Diabetic Ketoacidosis- patient with known T1DM with missed doses of insulin. Insulin normally transports glucose and potassium into cells therefore a lack of insulin causes hyperglycaemia and hyperkalaemia. As a result of the lack of glucose in cells the body starts to break down fat causing an increase in ketones. Ketones are acidic and hence cause metabolic acidosis, they can be smelt on patients breath as a sweet ‘pear-drop’ smell. Patients in DKA often take deep, fast breaths called Kusmall breaths- this is an attempt to ‘blow off’ CO2 to try and reverse the acidosis. It is important to recognise the ECG signs of hyperkalaemia as it can cause arrhythmias and subsequent death. Hyperkalaemia= Absent P, Long PR interval, Wide QRS, Tall Tented T waves (Go, Go long, Go wide, Go tall= Gonner). Hypokalaemia= U wave

Answer 89

D- Dilated Cardiomyopathy types: dilated, restrictive, hypertrophic. Cardiomyopathy is generally congenital and can also be idiopathic. Answers A,B,C,E are not types of cardiomyopathy, they are ways of describing potential ways in which cardiomyopathy may be acquired.

Answer 90

C- Lying 137/103, standing 109/88 Postural hypotension- 137/103 to 109/88 because 137-109= drop of 28mmHg. (A) Normal lying and standing BP response- 118/82 then increased to 138/90 (B) Narrow pulse pressure- 120/110 seen in aortic stenosis (D) Stage 1 hypertension- 147/99 (BP>140/90= stage 1) (E) Wide pulse pressure- 150/102 seen in aortic regurgitation

Answer 91

B- Smoke 20 cigarettes a day and has done for the last 10 years - Smoking is relevant as it is a significant risk factor for MI, his 10 year pack history is likely to play a role in his current presentation. (A) Cardiac family history is only applicable if it occurred before the age of 55. (C) Is irrelevant to his current presentation of chest pain given it was decades ago. (D) Thyroid disorders are also important when taking a history but out of the answers smoking is most relevant to the type of symptoms. (E) An allergy to penicillin is also very important, but the question asks specifically about making a diagnosis.

Answer 92

C- Bounding Pulse (A)- septic shock is caused by wide-spread infection in the blood therefore the patient will be pyrexic. (B)- bradycardia -a classical sign of cardiogenic shock- septic shock most likely to be tachycardic. (D)- reduced airway entry- anaphylactic shock because of swelling of the airways. (E) Paraesthesia isn’t a common feature of any type of shock. Therefore, the answer is C- bounding pulse.

Answer 93

E- Pulmonary Embolism. PE does not cause any form of fluid/blood loss. Hypovolemic shock is caused by blood/ fluid loss. (A) GI bleeding causes loss of blood. (B) severe diarrhoea/vomiting would cause loss of fluid. (C) burns cause loss of fluid. (D) pancreatitis is a known cause of hypovolaemic shock.

Answer 94

A- Aortic Dissection Aortic dissection typically is described as having a ‘tearing/shearing’ pain which goes to the back. Note that this can also be a symptom described in aortic aneurysm rupture- a medical emergency. (B) MI typically presents with central crushing chest pain. (C) Cardiac tamponade is caused by build up of fluid in the pericardial cavity but does not typically cause pain. (D) pulmonary embolism presents with pleuritic chest pain, SOB and haemoptysis. (E) infective exacerbation of COPD would likely present with respiratory symptoms such as SOB and productive cough.

Answer 95

C- pleuritic chest pain Pericarditis presents with pleuritic, sharp chest pain which classically is worse on lying down and relieved by leaning forwards. (A) is typical of MI. (B) is typical of acute pancreatitis. (E) haemoptysis is generally respiratory e.g TB, lung CA, PE.

Answer 96

E- Ultrasound Scan From the history of sudden onset epigastric pain and her vital signs indicating shock one diagnosis to work to exclude is a ruptured abdominal aortic aneurysm (AAA). This is done by performing a rapid USS of the aorta, if confirmed it requires immediate surgical repair.

Answer 97

A- Wide QRS, short PR, delta wave Wolf-Parkinson-white syndrome is a type of supraventricular tachycardia (SVT) caused when by an accessory pathway causing a re-entrant loop. The ECG findings are a wide QRS, short PR and a classical delta wave (slurred upstroke to the QRS).

Answer 98

A - Atrioventricular re-entry tachycardia AVRT is when re-entry point is an accessory pathway (e.g. in WPW) Supraventricular tachycardias are caused by the electrical signal of depolarisation re-entering the atria from the ventricles. atrioventricular nodal re-entrant tachycardia is when re-entry point is back through atrioventricular node Atrial tachycardia is where electrical signal originates in atria somewhere other than sinoatrial node (not technically caused by re-entering from ventricles but instead abnormally generated electrical activity in atria).

Answer 99

D- 0.12-0.20s The limits of normal for a P-R interval are 0.12-0.20s. PR changes: Prolonged PR interval is found in heart block, shortened PR interval found in WPW, PR depression found in pericarditis. 0.08-0.12s (B) is the normal range for QRS. Wide QRS found in R/L bundle branch block, hyperkalaemia, WPW, ventricular rhythm, tricyclic antidepressant poisoning. 0.40-0.44s (D) is the normal range for QTc.

Answer 100

B- HASBLED HASBLED is used to calculate risk of bleeding for patients on anticoagulants. (A)CHaDS2VaSc is used to determine likelihood of stroke in patients with AF. ABCD2 (C) is used to calculate the risk of stroke following suspected TIA. Wells (D) is used to calculate risk of DVT or PE- note there are 2 different risk scores depending on which one. QRisk (E) is used to calculate the risk of a cardiovascular event in next 10 years. Useful tip- download MedCalc app for all risk scores.

Answer 101

B- Cardiothoracic ratio <0.5 Patients in HF have ABCDE signs on CXR. A-alveolar oedema, B- Kerley B lines, C-cardiomegaly, D- dilated pulmonary vessels- E-pleural effusion. In normal patients the heart should take up <50% of the thoracic width, if it takes up >50% then this is cardiomegaly. Hence the correct answer here is B- in heart failure the cardiothoracic ration would be greater than 0.5 not less than.

Answer 102

D- B blocker and ACEi ACE- and B blockers are proven to improve prognosis in heart failure. Diuretics are useful in that they provide symptomatic relief but do not improve survival. Always important to start low, titrate slowly and start the ace and b blocker at different times.

Answer 103

A- Ascending loop of Henle Furosemide is a loop direct that inhibits the Na+/K+/2Cl- cotransporter channel on the ascending limb of the loop of Henle. Potassium-sparing diuretics e.g. amiloride act on distal convoluted tubule (C) inhibiting ENaC channels. Thiazide-like diuretics e.g. Bendroflumethiazide inhibit Na+Cl- cotransporter channels in the distal convoluted tubule (C).

Answer 104

A- Anterolateral

Answer 105

D- Pulmonary oedema secondary to mitral regurgitation Acute mitral regurg following MI occurs when territories suppling the papillary muscle or septum are affected causing them to rupture leading to valve incompetence. The murmur associated with mitral regurg is pansystolic- this is heard at the apex and may radiate to the axilla. Acute and severe mitral regurg can cause acute pulmonary oedema leading to breathlessness. Other complications of MI are remembered by mnemonic DARTH VADER- Death, Arrhythmias, Rupture (ventricular septum/papillary muscles), Tamponade, Heart failure (acute/chronic), Valve disease, Aneurysm of ventricle, Dressler’s syndrome, thromboEmbolism, Recurrence/mitral Regurg.

Answer 106

C - P2Y12 inhibitor Clopidogrel is an antiplatelet that prevents platelet aggregation by binding the P2Y12 receptor. COX inhibitors (A) are NSAIDS. HMG coA reductase inhibitors (B) are statins, Phosphodiesterase 5 inhibitors (D) are sildenafil, Vitamin K antagonists (E) are warfarin.

Cardio Practice Qs Flashcards

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