cardiology Flashcards
(222 cards)
1
Q
Ebstein’s anomaly → tricuspid regurgitation →
A
pansystolic murmur, worse on inspiration
Ebstein’s anomaly is a rare congenital heart defect that is characterised by apical displacement of the septal and posterior tricuspid leaflets onto the right ventricular wall, leading to atrialisation of part of the right ventricle. Severe cases often present in infancy but milder cases can remain asymptomatic until adulthood. This commonly presents with arrhythmia and shortness of breath predominantly on exertion. ECG changes include right bundle branch block and Wolf-Parkinson-White (WPW) syndrome due to aberrant conduction pathways. Echocardiography will be useful in the diagnosis.
2
Q
Pulmonary arterial hypertension patients with positive response to vasodilator testing should be treated with
more than 25 and more than 35 after exercise
A
calcium channel blocker
Bosentan and ambrisenton is an endothelin receptor antagonist, along with ambrisentan, that can be used if there is a negative response to vasodilator testing
carries a risk of venous-occlusive disease
Iloprost is a prostacyclin analogue that can also be used when there is a negative response to vasodilator testing
ontraindicated in decompensated heart failure and valvular disease
Sildenafil is a phosphodiesterase inhibitor that must be avoided in the concomitant use of nitrates
3
Q
past medical history of heart failure His regular medications include ramipril, bisoprolol, furosemide and eplerenone
His pulse rate is 65 beats per minute.
most likely to be beneficial to long-term survival?
A
Sacubitril-valsartan is considered the next line in patients with a left ventricular ejection fraction (LVEF) < 35% who are still symptomatic on an ACE inhibitor and beta-blocker.
Ivabradine is recommended as an option for treating chronic heart failure for patients who are in sinus rhythm with a heart rate of 75 beats per minute or more and who are already on standard therapy with ACE inhibitors, beta-blockers and aldosterone antagonists
4
Q
infective endocarditis (IE), including fever, pan-systolic murmur, and splinter haemorrhages
A
IV amoxicillin + gentamicin is the correct answer. According to UK guidelines (British Society for Antimicrobial Chemotherapy), the first-line empirical treatment for native valve endocarditis in patients who are not allergic to penicillin is a combination of amoxicillin (or benzylpenicillin) with gentamicin
5
Q
Prosthetic heart valves - antithrombotic therapy:
bioprosthetic:
mechanical:
A
aspirin
warfarin + aspirin
Target INR
aortic: 3.0
mitral: 3.5
6
Q
Digoxin normally binds to the ATPase pump on the same site as potassium. Hypokalaemia →
A
digoxin more easily bind to the ATPase pump → increased inhibitory effects
7
Q
Persistent ST elevation following recent MI, no chest pain -
A
left ventricular aneurysm
Following a transmural MI, especially an anterior infarct, scar tissue may form and lead to thinning and bulging of the ventricular wall. This can result in a left ventricular aneurysm, which classically presents with persistent ST elevation on ECG weeks after the initial event, often accompanied by Q waves but typically without recurrent chest pain
Dressler’s syndrome occurs several weeks post-MI as an autoimmune response, presenting with fever, pleuritic chest pain and sometimes pericardial effusion. While it may cause widespread ST elevation due to pericarditis
Ventricular septal defect typically develops within a week of MI due to septal rupture and presents acutely with heart failure signs (e.g., pulmonary oedema), a new loud pan-systolic murmur and rapid clinical deterioration
Acute pericarditis would present soon after MI (within days), causing sharp pleuritic chest pain relieved by sitting forward, possibly a pericardial rub, and widespread concave (‘saddle-shaped’) ST elevations across multiple leads rather than being localised to previous infarcted regions.
8
Q
Bendroflumethiazide predisposes to , rather than pseudogout
A
gout
9
Q
Amiodarone has a long half-life - it is highly lipophilic and widely absorbed by tissue, which reduces its bioavailability in serum.
A
Therefore, a prolonged loading regime is required to achieve stable therapeutic levels
increase qt interval
Class | Mechanism (Target) | Example Drugs | Key Effects | Clinical Use |
10
Q
NICE guidelines state that for recurrent DVT (while on anticoagulation) the target INR should be ……The target INR for a metallic aortic valve alone is ….., while for a prosthetic valve with history of systemic embolism (DVT) the target would be …….
A
3.5.
3.0
2.5.
11
Q
What does troponin T bind to?
Within the troponin complex, it is …….. that binds to calcium ions, not troponin T
A
Tropomyosin
troponin C
12
Q
Beck’s triad of falling BP, rising JVP and muffled heart sound is characteristic of
A
cardiac tamponade
13
Q
Aortic stenosis - most common cause:
younger patients < 65 years: ………
older patients > 65 years:
The hallmark finding is a harsh ejection systolic murmur best heard at the right 2nd intercostal space, radiating to the carotids. The murmur becomes louder with expiration and squatting, and softer with Valsalva. In severe cases, S2 is soft or absent
A
bicuspid aortic valve
calcification
14
Q
If angina is not controlled with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be added
A
only modified-release nifedipine should be used to improve symptom control whilst avoiding the risk of heart block dysrhythmias
15
Q
Whilst useful in managing the symptoms of acute and chronic heart failure ………. offers no prognostic benefits.
A
furosemide
1st line ace inhibitor and beta blocker
2nd line aldosterone antagonist
3rd line ivabradine
criteria: sinus rhythm > 75/min and a left ventricular fraction < 35%
sacubitril-valsartan
criteria: left ventricular fraction < 35%
is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs
digoxin if AF
hydralazine and cardiac resynchronization therapy
16
Q
Pregnancy-induced hypertension systolic more than 140 in association with proteinuria (> 0.3g / 24 hours
after 20 week of pregnancy
A
chronic is otherwise
headache, epigastric pain is most common symptoms HELPP low platelets
17
Q
Adrenaline induced ischaemia -
A
phentolamine
18
Q
Class I agents are sodium channel blockers and include ………… which can be used either continuously (i.e. taken every day)
A
flecainide
digoxin is reserved for pt with no repond to it
19
Q
This patient has aortic regurgitation, which can present with symptoms including dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. He is at risk of aortic regurgitation due to his history of rheumatic fever. Further signs are the wide pulse pressure (114mg) and nail-bed pulsation (Quincke’s sign).
A
Aortic regurgitation is associated with an early diastolic murmur, loudest on expiration. When severe, aortic regurgitation can be associated with a mid-late diastolic murmur (also known as an Austin-Flint murmur)
20
Q
svt is associated with av synchorny each p wave is proceeded by qrs with narrow qrs
A
VT HAS atrioventricular (AV) dissociation, which is one of the most specific findings for ventricular tachycardia (VT). This is evidenced by P waves that are clearly dissociated from the QRS complexes, with more QRS complexes than P waves. The patient also has multiple other features strongly suggestive of VT: a very broad QRS complex (170 ms, which exceeds the 160 ms threshold that favours VT), positive concordance across the precordial leads (where all QRS complexes in the chest leads point in the same direction), and a northwest axis (marked left axis deviation)
21
Q
,,,,,,,,,,,,,,,,,,, cause an ejection systolic murmur, louder on inspiration, and a fixed split S2.
A
Atrial septal defects (ASD)
cause epstein anamoly
22
Q
management of pre eclampsia
A
Magnesium sulphate - monitor reflexes + respiratory rate
23
Q
…………….. has been shown to potentiate the anticoagulant effect of warfarin by inhibiting the cytochrome P450 2C9 (CYP2C9) enzyme system, which is responsible for metabolising warfarin.
A
Cranberry juice
St John’s Wort actually has the opposite effect on warfarin metabolism. It induces the CYP2C9 enzyme system, leading to increased warfarin metabolism and consequently reduced anticoagulant effect and lower INR values
24
Q
…………. is present in around 20% of the population. It may allow embolus (e.g. from DVT) to pass from right side of the heart to the left side leading to a stroke - ‘a paradoxical embolus’
A
Patent foramen ovale (PFO)
25
Patients with VT should not be prescribed ............
verapamil
26
Complete heart block causes a
variable intensity of S1
3rd heart sound... HEART FAILURE
Quiet S1 is incorrect. A quiet S1 is characteristically caused by mitral valve regurgitation
A quiet S2 is associated with aortic stenosis
27
Statins + erythromycin/clarithromycin - an important and common interaction
xoxo
28
Prosthetic valve endocarditis caused by staphylococci →
Flucloxacillin + rifampicin + low-dose gentamicin
29
pulmonary component of the second heart sound occurs before the aortic. Which one of the following is associated with this finding?
Second heart sound (S2)
loud: hypertension
soft: AS
fixed split: ASD
reversed split: LBBB
30
ACE inhibitors prevent the breakdown of inflammatory peptides such as .......... and cough is a frequent side effect.
bradykinin
31
Systolic anterior motion of the mitral valve is a characteristic finding in HOCM that contributes to left ventricular outflow tract obstruction and mitral regurgitation
Asymmetric septal hypertrophy with a wall thickness of 3.2 cm is the correct answer and represents a significant poor prognostic factor in hypertrophic obstructive cardiomyopathy (HOCM). A septal wall thickness exceeding 3 cm is associated with an increased risk of sudden cardiac death and other adverse outcomes
32
Mutations in the ............. (which encode the myocardial sodium ion channel protein are the most common gene abnormality seen in Brugada syndrome
SCN5A gene
PRKAG2 encodes for a protein kinase enzyme that is implicated in Wolff-Parkinson White syndrome
convex ST segment elevation > 2mm in > 1 of V1-V3 followed by a negative T wave
partial right bundle branch block
the ECG changes may be more apparent following the administration of flecainide or ajmaline - this is the investigation of choice in suspected cases of Brugada syndrome
Management
implantable cardioverter-defibrillator
33
Prominent V waves on JVP → tricuspid regurgitation
Signs
pan-systolic murmur
prominent/giant V waves in JVP
pulsatile hepatomegaly
left parasternal heave
34
Percutaneous mitral commissurotomy is the intervention of choice for severe
mitral stenosis
35
The renoprotective effects of ACE inhibitors are mediated through dilation of the
glomerular efferent arteriole
36
Which of the following congenital heart defects may progress to Eisenmenger's syndrome?
Eisenmenger's syndrome describes the reversal of a left-to-right shunt in a congenital heart defect due to pulmonary hypertension. This occurs when an uncorrected left-to-right leads to remodeling of the pulmonary microvasculature, eventually causing obstruction to pulmonary blood and pulmonary hypertension.
Patent ductus arteriosus
37
Flecainide blocks the ................. in the heart
Nav1.5 sodium channels
Calcium channel blockers represent a different class of antiarrhythmic medications (Class IV). While they are useful in treating arrhythmias
Potassium channel blocker describes Class III antiarrhythmic drugs like amiodarone and sotalol. These medications work by prolonging the action potential duration and effective refractory
ADP receptor antagonist describes antiplatelet medications like clopidogrel
38
Pulmonary embolism - normal CXR
elative frequency of common clinical signs is shown below:
Tachypnea (respiratory rate >20/min) - 96%
Crackles - 58%
Tachycardia (heart rate >100/min) - 44%
Fever (temperature >37.8°C) - 43%
39
heparin-induced thrombocytopenia (HIT) with thrombosis. Characteristic features include the development of new thrombosis following the commencement of unfractionated heparin, which is typical for HIT, pronounced thrombocytopenia, and the appearance of petechiae and purpura that may signify microvascular thrombosis or platelet consumption
Heparin-induced thrombocytopaenia - antibodies form against complexes of platelet factor 4 (PF4) and heparin
40
Based on the type of valve replacement this patient likely received, what medication will he be taking?
Warfarin
41
......... can caused decreased BNP levels, leading to a false negative for heart failure screening
Obesity
Hypertension can cause increased BNP levels.
Females generally have higher BNP levels.
Other causes of a raised BNP include lung conditions such as COPD or pneumonia, sepsis, other cardiac causes such as AF and valve disease, liver disease, older age, sepsis and chemotherapy.
Other causes of a low BNP include flash pulmonary oedema (the presentation here is more insidious), pericardial constriction, and use of ACE-is, ARBs and diuretic
42
Patients with...................... typically present with progressive exertional dyspnoea as in this case. They may also experience chest pain, syncope, palpitations and peripheral oedema. Examination findings can include peripheral cyanosis and oedema, a parasternal heave, loud pulmonary component of the second heart sound, raised JVP with a prominent A wave and small volume pulse.
pulmonary arterial hypertension
43
Atrial myxoma most commonly attached to the fossa ovalis
ystemic: dyspnoea, fatigue, weight loss, pyrexia of unknown origin, clubbing
emboli
atrial fibrillation
mid-diastolic murmur, 'tumour plop'
echo: pedunculated heterogeneous mass typically attached to the fossa ovalis region of the interatrial septum
44
Statins inhibit the action of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis.
myopathy: includes myalgia, myositis, rhabdomyolysis and asymptomatic raised creatine kinase
liver impairment
LFTs at baseline, 3 months and 12 months
45
When treating angina, if there is a poor response to the first-line drug (e.g. a beta-blocker), the dose should be titrated up before adding another drug
The BNF recommends an atenolol dose of 100mg daily in 1 or 2 doses for angina. The starting dose of isosorbide mononitrate is 10mg bd.
46
............. can cause hyponatraemia, metabolic alkalosis, hypokalaemia and hypocalciuria
............use may be associated with visual disturbances including phosphenes and green luminescence
Thiazide diuretics
Ivabradine
47
Congenital heart disease
cyanotic: TGA most common at birth, Fallot's most common overall
acyanotic: VSD most common cause
Mechanical valves have a lower failure rate than bioprosthetic valves
48
sotalol and amaidrone cause
prolong QT
49
Ventricular tachycardia - ............. is contraindicated
verapamil
50
...................... is the first line investigation for stable chest pain of suspected coronary artery disease aetiology
Contrast-enhanced CT coronary angiogram
51
Eisenmenger's syndrome is characterised by the reversal of the left-right shunt due to pulmonary hypertension. ..................... once Eisenmenger's syndrome develops
The original murmur may disappear
52
Palpitations should first be investigated with a Holter monitor after initial bloods/ECG
72 hour Holter monitor
53
Women with ................ should avoid becoming pregnant due to very high mortality levels
pulmonary hypertension
54
Brugada syndrome - conduction abnormality associated with arrhythmias. ST elevation in V1-V3 and then t wave inversion Mutation in the gene encoding the myocardial sodium ion channel SCN5A are seen on ECG.
Cardiac syndrome X - also called microvascular angina. Patients have a normal ECG at rest and normal coronary arteries but develop ST depression on exercise stress testing.
Wolff-Parkinson-White syndrome - electrical conductivity disorder. Delta waves are seen on ECG along with shortened PR interval.
55
after AF the risk of stroke is determined by chadvasc
0 No treatment
1 Males: Consider anticoagulation
Females: No treatment (this is because their score of 1 is only reached due to their gender)
2 or more Offer anticoagulation (DOAC not warfarin )
congestive heart disease
hypertension
age more than 75 2 score
65 to 75 q score
diabetes
Prior Stroke, TIA or thromboembolism 2
Vascular disease (including ischaemic heart disease and peripheral arterial disease) 1
Sex (female)
56
neprilysin inhibitor, sacubitril
Prevents the degradation of natriuretic peptides such as BNP and ANP
57
Witnessed cardiac arrest while on a monitor - up to three successive shocks before CPR IN PULSELESS VT
Amiodarone should also be given after the third shock - not immediately.
58
Hypokalemia (low potassium), hypomagnesemia (low magnesium), and hypercalcemia (high calcium) can exacerbate toxicity.
hypercalcemia not hypo psycho
59
The most specific ECG finding in acute pericarditis is
PR depression
not convave st eleveation despite its more sensitive but not specific
60
If high-risk of failure of cardioversion (previous failure), offer electrical cardioversion after at least ............
4 weeks treatment with amiodarone
61
Ticagrelor has a similar mechanism of action to clopidogrel -
inhibits ADP binding to platelet receptors
61
Aortic regurgitation typically causes an ......
Aortic stenosis causes crescendo-decrescendo systolic ejection murmur, meaning it gets louder (crescendo) and then softer (decrescendo)
Mitral stenosis causes late diastolic murmur
mitral regurgitation systolic murmur
early diastolic murmur
Causes of AR can be due to valve disease (e.g. bicuspid aortic valve, aortic dissection, spondyloarthropathies (e.g. ankylosing spondylitis) and connective tissue disease) or due to aortic root disease (e.g. rheumatic fever, calcific valve disease, infective endocarditis and connective tissue diseases).
62
fibrinolysis should be offered within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes
Amiloride is a potassium-sparing diuretic. Specifically, it inhibits the epithelial sodium channels found in the distal convoluted tubule
63
Most common cause of endocarditis after a procedure :
Staphylococcus aureus
................if < 2 months post valve surgery
Staphylococcus epidermidis
64
Tricuspid valve endocarditis can cause tricuspid regurgitation, which may manifest with a new pan-systolic murmur, large V waves and features of pulmonary emboli
hf after MI is a sign of bad prognosis
65
neonate is cyanosed and lethargic. Her vital signs were as follows: respiratory rate 62/min, oxygen saturation 84% (on 60% oxygen), heart rate 160/min, blood pressure 96/66 mmHg. Cardiac auscultation reveals a loud S2 heart sound.
Chest x-ray shows the cardiac silhouette with an 'eggs on a string' appearance. Electrocardiogram (ECG) shows a right ventricular dominance
Transposition of great vessels is due to the failure of the aorticopulmonary septum to spiral
66
Patients with a suspected pulmonary embolism should be initially managed with a direct oral anticoagulant (DOAC)
for 3 month
67
A patient is given aspirin 300 mg after developing an acute coronary syndrome. What is the mechanism of action of aspirin to achieve an antiplatelet effect?
What is the mechanism of action of bivalirudin in acute coronary syndrome?
What is the mechanism of action of Tirofiban?
Hydralazine - increases cGMP leading to smooth muscle relaxation
Inhibits the production of thromboxane A2
Reversible direct thrombin inhibitor
GpIIb/IIIa inhibitor
endothelin receptor antagonist?
Endothelin receptor antagonists decrease pulmonary vascular resistance in patients with primary pulmonary hypertension.
68
What is the mechanism of action of this LMWH?
Activation of antithrombin III which inhibits factor Xa
Warfarin inhibits the formation of the vitamin K dependent clotting factors II, VII, IX and X.
Dabigatran is a direct thrombin inhibitor.
Aspirin inhibits the formation of thromboxane A2.
Apixaban, rivaroxaban and edoxaban are direct factor Xa inhibitors.
LMWH also inhibits factor Xa but does so via activation of antithrombin III.
69
During examination of his JVP he is noted to have regular cannon waves. Which one of the following arrhythmias is most likely to be responsible for this finding?
Atrio-ventricular nodal re-entry tachycardia
aused by the right atrium contracting against a closed tricuspid valve. May be subdivided into regular or intermittent
Regular cannon waves
ventricular tachycardia (with 1:1 ventricular-atrial conduction)
atrio-ventricular nodal re-entry tachycardia (AVNRT)
Irregular cannon waves
complete heart block
70
Pulmonary stenosis ejection systolic murmur is louder on inspiration
Tricuspid regurgitation becomes louder during inspiration.
Aortic stenosis ejection systolic murmur heard loudest in expiration.
mitral regurgitation becomes louder during expiration.
71
What is the main reason for checking the urea and electrolytes prior to commencing a patient on amiodarone?
To detect hypokalaemia
34%
All antiarrhythmic drugs have the potential to cause arrhythmias. Coexistent hypokalaemia significantly increases this risk.
72
pressure in arota is 120/80 mean 95 in left ventricle it is 150/5-10
pressure in right ventricle and pulmonary artery is 15-30 and diastolic 0-8 in right ventricle and 3-12 in PA, mean pressure in right atrium is 0-8, pulmonary artery 9-16 and Pulmonary Capillary Wedge Pressure is 1- 10
74 is oxygen saturaation in rt side of heart and 98 in left
73
rare but serious side effects of .............is angioedema, characterised by marked tongue and facial swelling
ACE inhibitors
73
treated with intravenous benzylpenicillin and gentamicin. What is the most important ECG change to monitor for?
A prolonged PR interval - aortic root abscess
74
............. should be continued indefinitely life long as this is his second episode of atrial fibrillation and he has risk factors for stroke (age, hypertension). As he has a history of valvular heart disease, warfarin is still preferred to a direct oral anticoagulant.
Warfarin
75
The main ECG abnormality seen with ............... is shortening of the QT interval
hypercalcaemia
76
murmur of aortic regurgitation and more definitively by CT evidence of a dissection flap proximal to the brachiocephalic vessels indicating the involvement of the ...................
ascending aorta
77
Prosthetic heart valves - antithrombotic therapy:
bioprosthetic: aspirin
mechanical: warfarin + aspirin
Myoglobin rises first following a myocardial infarction
78
Pulsus paradoxus
greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration
severe asthma, cardiac tamponade
Slow-rising/plateau
aortic stenosis
Collapsing
aortic regurgitation
patent ductus arteriosus
hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)
Pulsus alternans
regular alternation of the force of the arterial pulse
severe LVF
Bisferiens pulse
'double pulse' - two systolic peaks
mixed aortic valve disease
'Jerky' pulse
hypertrophic obstructive cardiomyopathy*
*HOCM may occasionally be associated with a bisferiens pulse
79
Cardiac resynchronisation therapy
for patients with heart failure and wide QRS
biventricular pacing (CRT-P or CRT-D)
Indicated in patients with LVEF ≤35%, QRS ≥120 ms (especially LBBB), and persistent symptoms despite optimal medical therapy (cardiac resynchorization therapy)
The key diagnostic tests used to identify patients likely to benefit from cardiac resynchronization therapy is the transthoracic echocardiogram and ECG.
80
Which one of the following would not be considered a normal variant on the ECG of an athletic 28-year-old man?
LBBB
81
Preterm infants with haemodynamically significant patent ductus arteriosus 1 week after birth - give ...................to promote duct closure
ibuprofen/indomethacin INHIBIT prostaglandin synthesis
prostaglandin E1 is useful to keep the duct open until after surgical repair
82
Which one of the following is least likely to cause dilated cardiomyopathy?
Wilson's disease
most likelycause is genetic
most likely infectious cause is Coxsackievirus B (viral)
83
Recommend Adult Life Support (ALS) adrenaline doses
anaphylaxis: 0.5mg - 0.5ml 1:1,000 IM
cardiac arrest: 1mg - 10ml 1:10,000 IV or 1ml of 1:1000 IV
Patients with very poor dental hygiene may develop endocarditis secondary to Viridans streptococci e.g. Streptococcus sanguinis
84
Furosemide - inhibits the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle
Indapamide is incorrect as it is a thiazide-like diuretic that primarily works by inhibiting the sodium-chloride symporter (NCC) in the proximal part of distal convoluted tubule.
85
HOCM is usually due to a mutation in the gene encoding
β-myosin heavy chain protein or myosin binding protein C
86
This patient has experienced a recurrent deep vein thrombosis (DVT) despite being adequately anticoagulated with warfarin (INR consistently above 2.0 for three months). This represents a failure of standard anticoagulation therapy, which requires escalation of treatment. In cases of recurrent thrombosis despite therapeutic anticoagulation, the recommended approach is to increase the intensity of anticoagulation by raising the target INR to...............
3.5 (range 3.0-4.0).
87
Ticagrelor-related dyspnoea is transient and lasts a few hours or days, generally occurring within the first week of treatment which is what this patient is experiencing.
Dyspnoea in ticagrelor-treated patients is due to the ....................
impaired clearance of adenosine
DVLA advice following angioplasty - cannot drive for 1 week
88
The administration of adenosine is contraindicated by her history of ............. Verapamil should therefore be given
asthma
89
In systemic sclerosis, pulmonary arterial hypertension (PAH) is a common complication and it often presents with exertional dyspnoea.
Acute vasodilator testing should be used in patients with pulmonary artery hypertension to determine which patient show a significant fall in pulmonary arterial pressure following vasodilators and help guide treatment
90
............................ would indicate left ventricular dilatation and hence severe disease
Displacement of apex beat in aortic stenosis
91
What is the most appropriate pharmacological management option for this patient of WPWS?
av nodal blocking drugs like flecainide
92
Bleeding on dabigatran? Can use ................ to reverse
................ is incorrect. This medication is used to reverse the effects of heparin.
.............. is a 5-HT2 receptor antagonist which can be used for peripheral vascular disease
idarucizumab
Protamine sulphate
Naftidrofuryl
93
Digoxin - inhibits the
Na+/K+ ATPase pump
94
severe aortic stenosis, the .............................. due to the reduced mobility and increased calcification of the aortic valve cusps.
second heart sound (A2) becomes soft or absent
determine severity of the disease
95
V'Unprovoked' pulmonary embolisms are typically treated for
6 month
provoked recent surgery is treated for 3 months
96
................... is correct. Calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression.
Calcium gluconate
u will look for respiratory rate and deep tendon reflexes in magnesium sulphate adminitration
Right axis deviation - left posterior hemiblock
97
Dipyridamole an antiplatelet agent is a non-specific ............................ and decreases cellular uptake of adenosine
phosphodiesterase inhibitor
98
.......................... have been associated with myositis, especially when combined with a statin
fibrates (bezafibrate) and nicotinic acid
99
................ can lead to long QT syndrome more than 440 or 0.44s
Hypokalaemia
shortened QT interval,is caused by hypercalcemia
99
Erythromycin can cause a ...............
prolonged QT interval
100
verapamil can cause
constipation, peripheral edema, gingivial hyperplasia, headache hypotension, beady cardia
101
....................... is characterised by right ventricular myocardium replaced by fatty and fibrofatty tissue
Arrhythmogenic right ventricular cardiomyopathy
102
During exercise, diastolic blood pressure typically remains stable or may even decrease slightly due to the vasodilation of blood vessels in active skeletal muscles.
Venous constriction does occur during exercise as part of the cardiovascular response
vasodilation occue in muscle
103
.................... as it is not typically associated with aortic regurgitation.
dilated cardiomyopathy,
sypillus does
104
Most common cause of endocarditis:
Staphylococcus aureus
Staphylococcus epidermidis if
< 2 months post valve surgery
105
......................... should be considered during CPR if a PE is suspected
Thrombolytic drugs
Lidocaine is indicated during cardiac arrest when the underlying rhythm is pulseless ventricular tachycardia or ventricular fibrillation.`
106
Inherited long QT syndrome, sensorineural deafness -
Jervell and Lange-Nielsen syndrome
107
Patients with drug-eluting stents require a shorter duration of clopidogrel therapy
atleat 6 months
Restenosis is more common than stent thrombosis
Nifedipine should be avoided in heart failure due to risk of symptom exacerbation
108
Adenosine
............. enhances effect
............... reduces effect
dipyridamole
aminophylline
109
...............is not a risk factor for the development of pre-eclampsia
Smoking
nulliparity is somehow
110
pulmonary capillary wedge pressure. Which chamber of the heart does this pressure generally equate to?
Left atrium
Swan-Ganz catheter is inserted to enable measurement of the pulmonary capillary wedge pressure
111
Chest compressions are paused briefly so that the rhythm can be analysed: pulseless electrical activity is observed.
what to do
ALS - give adrenaline in non-shockable rhythm as soon as possible
112
Anti-Factor Xa levels are the most appropriate blood test to perform in this situation as they directly measure the activity of LMWH
LMWHs exert their anticoagulant effect by enhancing the activity of antithrombin III,
113
Which one of the following best describes the primary mechanism of action of amiodarone?
Blocks voltage-gated potassium channels
114
.................... can be used in patients presenting with signs and symptoms suggestive of PE to guide the next investigation
The two level Well's score
115
An ECG taken in clinic shows T wave inversion in leads V1-3 associated with a notch at the end of the QRS complex. He is known to have a family history of sudden cardiac death. What is the most likely diagnosis?
Arrhythmogenic right ventricular cardiomyopathy
116
Second heart sound (S2)
loud:
soft:
fixed split:
reversed split:
hypertension
AS
ASD
LBBB
Aortic stenosis - S4 is a marker of severity
117
Syndrome X, also known as cardiac syndrome X or microvascular angina, typically presents with angina-like chest pain and ST depression during stress testing
Which one of the following is least associated with ST depression on ECG?
Acute pericarditis
118
Adrenaline induced ischaemia -
phentolamine
119
Electrocardiogram (ECG): ST-segment elevation in lead I, II, III, aVL, V5 and V6. PR segment elevation in aVR.
What is the most likely diagnosis in this patient?
Pericarditis
Global ST and PR segment changes: think pericarditis
120
Which one of the following agents is most useful in the maintenance of sinus rhythm in patients with atrial fibrillation?
Amiodarone
121
A 67-year-old female is prescribed simvastatin for hyperlipidaemia. Which one of the following is most likely to interact with her medication
grapefruit juice
it should be noted that cranberry juice may interact with other medications such as warfarin
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The patient is taking indapamide, a thiazide-like diuretic, which acts on the early (proximal) part of the distal convoluted tubule by blocking the Na⁺/Cl⁻ symporter.
This leads to:
Increased sodium delivery to the distal nephron (late DCT & collecting duct)
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S3 (third heart sound)
caused by diastolic filling of the ventricle
considered normal if < 30 years old (may persist in women up to 50 years old)
heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation
S4 (fourth heart sound)
may be heard in aortic stenosis, HOCM, hypertension
caused by atrial contraction against a stiff ventricle
therefore coincides with the P wave on ECG
in HOCM a double apical impulse may be felt as a result of a palpable S4
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................... is a glucose analog where the hydroxyl group at the 2' position is replaced by fluorine-18, a radioactive isotope of fluorine. It's primarily used in cardiac Positron Emission Tomography (PET) scans to assess myocardial viability
Fluorodeoxyglucose (FDG)
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............. can cause first dose hypotension
ACE inhibitors
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.............conserves potassium by blocking epithelial sodium channels in the distal convoluted tubule and collecting ducts, reducing sodium reabsorption and subsequent potassium secretion
Amiloride
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............. is associated with QT interval prolongation; ...................... is associated with QT interval shortening
Hypocalcemia
Hypercalcemia
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Atrial septal defect (ostium secundum) doesnt cause
Each one of the following is associated with aortic dissection, except:
LBBB
Ventricular septal defect
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....................... remains elevated for 3 to 4 days following infarction. Troponin remains elevated for 10 days. This makes CK-MB useful for detecting re-infarction in the window of 4 to 10 days after the initial insult
Creatine kinase (CK-MB)
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................... is a monoamine oxidase inhibitor (MAOI), a class of drugs rarely used now in part due to the risk of hypertensive crises.
Phenelzine
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Long QT syndrome type I (LQTS1) causing potentially life-threatening arrhythmias. Certain drugs, including some antidepressants such as ................, can exacerbate these arrhythmias in patients with LQTS1
sertraline
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sotalol have on the cardiac cell membrane to make this more likely?
Blockage of potassium channels
Long QT syndrome - usually due to loss-of-function/blockage of K+ channels
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Elective surgery should be postponed until completion of this mandatory period of DAPT
Following insertion of a drug-eluting stent (DES), dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is essential for 12 months to prevent in-stent thrombosis
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Dentistry in warfarinised patients - check INR 72 hours before procedure, proceed if INR
< 4.0
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His mother has a history of bipolar disorder and was on lithium throughout her pregnancy can cause which disease in child
Ebstein's anomaly → tricuspid regurgitation → pansystolic murmur, worse on inspiration
vsd is worst on expiration
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Ventricular tachycardia - ............... is contraindicated
verapamil
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Heart failure is one of the adverse signs indicating the need for urgent ............. in AF
synchronised DC cardioversion
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Adrenaline induces /............................. Because insulin secretion is suppressed by alpha adrenergic stimulation, plasma concentration of insulin remains low
hyperglycemia, hyperlactatemia and hypokalaemia
139
Which one of the following complications is least associated with ventricular septal defects?
Atrial fibrillation
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Positive QRS concordance in the chest leads is associated with
ventricular tachycardia
141
NICE) guidelines in the UK, statins should be offered to people who have a ...................year risk of developing cardiovascular disease (CVD).
10% or greater 10-
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that previous question was AF with WPW .answer is
this one is AF alone rate control is by ............. and in hf with af controlled by
flecanide
beta blocker
digoxin
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,............, is contraindicated in Wolff-Parkinson-White (WPW) syndrome.
Verapamil
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The renoprotective effects of ACE inhibitors are mediated through
dilation of the glomerular efferent arteriole
it inhibit the aldosterone who constrict the efferent arteriole
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Cholesterol embolisation, also known as atheroembolic disease, is a systemic illness caused by the showering of cholesterol crystals from atherosclerotic plaques. These can lodge in small vessels causing inflammation and tissue damage. ................is often seen in this condition due to the inflammatory response to the cholesterol crystals.
Eosinophilia
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verapamil can cause
constipation
147
........... is used in the treatment of primary pulmonary hypertension
Prostacyclins
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Which one of the following conditions is most associated with aortic dissection?
Methadone is a common cause of
Bicuspid aortic valve
QT prolongation
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aortic abscess (often indicated by a lengthening PR interval
is a indication for surgery in infective endocarditis
150
eruptive xanthoma most commonly associated with?
Familial hypertriglyceridaemia
151
BNP level below 100 pg/ml has a high negative predictive value for heart failure, making it less likely as the cause of this patient's symptoms.
Aschoff bodies are granulomatous nodules found in rheumatic heart fever
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New onset AF is considered for ................. if it presents within 48 hours of presentation
electrical cardioversion
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Patent ductus arteriosus - large volume, bounding,
collapsing pulse
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The most accurate method to determine the left ventricular function in this patient is the ......................., also known as radionuclide ventriculography or nuclear angiography, is a non-invasive nuclear medicine test that uses a small amount of radioactive tracer to evaluate the pumping function of the heart
MUGA scan. MUGA (multigated acquisition) scan
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Which one of the following is least recognised as an adverse effect of taking bendroflumethiazide?
Hirsutism
it cause pancreatitis
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Nicorandil is a vasodilatory drug that acts as both a nitrate and a non-selective
potassium channel activator.
157
Rate-limiting .......... should be avoided in patients with AF with heart failure with reduced EF (HFrEF) due to their negative inotropic effects
CCBs
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entricular tachycardia (VT) with a QRS complex duration of 150ms.
With regard to the JVP waveform, which of these features would you expect to see?
Cannon a waves
159
What is the mechanism of action of fondaparinux?
Activates antithrombin III
160
Massive PE + hypotension -
thrombolyse
161
Brugada syndrome is due to a mutation of the myocardial
sodium ion channel protein
162
Which one of his medications is most likely to have contributed to torsades de pointes
Risperidone
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pulse? - seen in left ventricular failure
Pulsus alternans
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Which one of the following drugs is most likely to improve his long-term prognosis of angina?
Aspirin
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BNP - actions:
New LBBB is always pathological and never normal
vasodilator: can decrease cardiac afterload
diuretic and natriuretic
suppresses both sympathetic tone and the renin-angiotensin-aldosterone system
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Takayasu's arteritis is the correct diagnosis in this case. The presentation is typical: a young woman of Asian origin with constitutional symptoms (headache, malaise, joint pains), claudication symptoms, and most importantly, a significant blood pressure difference between arms (>20 mmHg)
The presence of carotid bruits and an aortic diastolic murmur (suggesting aortic regurgitation) are also characteristic features of Takayasu's arteritis, which is a large vessel vasculitis primarily affecting the aorta and its major branches.
167
.......................... is the intervention of choice for severe mitral stenosis
Percutaneous mitral commissurotomy
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patients who have been successfully cardioverted should continue anticoagulation therapy for at
least four weeks after the procedure.
169
Which of the following is least associated with a poor prognosis in hypertrophic cardiomyopathy?
Reduced left ventricular outflow gradient
170
..................... is the subtype of Streptococcus bovis most linked with colorectal cancer
Streptococcus gallolyticus
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Arrhythmogenic right ventricular cardiomyopathy is characterised by right ventricular myocardium replaced by fatty and fibrofatty tissue
Her 12-lead ECG at rest shows sinus rhythm with T wave inversion in V1-3, with a small positive deflection at the end of the QRS complexes in V1-3.
A 24-hour Holter monitor shows evidence of frequent premature ventricular complexes and runs of non-sustained ventricular tachycardia.
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Risk of falls or old age alone is not sufficient reasoning to withhold anticoagulation
Infective endocarditis - strongest risk factor is previous episode of infective endocarditis
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Statins + erythromycin/clarithromycin - an important and common interaction
rhabdomyolysis
174
Digoxin moa -
inhibits the Na+/K+ ATPase pump
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troponin is a component of the .................. Troponin is a complex of three regulatory proteins (troponin C, troponin I, and troponin T) that is integral to muscle contraction in skeletal and cardiac muscle. Located on the actin filament,
thin filaments
troponin works in conjunction with tropomyosin to regulate the interaction between actin and myosin. When calcium binds to troponin C, it causes a conformational change that moves tropomyosin away from the myosin-binding sites on actin, allowing cross-bridge formation and muscle contraction.
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The ............... on the jugular venous waveform corresponds to the fall in atrial pressure during ventricular systole. This occurs as the tricuspid valve closes and the right ventricle contracts, reducing the volume of the right atrium and thus causing a drop in pressure. The x descent is therefore a reflection of ventricular systole.
x descent
Tricuspid open in early diastole and blood move to ventricle from atrai and cause y decent
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Which one of the following drugs causes shortening of the QT interval?
Digoxin
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First line management of acute pericarditis involves
combination of NSAID and colchicine
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Aortic stenosis - most common cause:
younger patients < 65 years: bicuspid aortic valve
older patients > 65 years: calcification
calcification cause degenrative tricuspid aortic stenois
180
What is the mechanism of action of this drug?
tirofiban
Glycoprotein IIb/IIIa receptor antagonist
181
Bendroflumethiazide causes both hyponatraemia and hypokalaemia.
Spironolactone is associated with hyperkalaemia
182
Dilated cardiomyopathy may be caused by deficiency of which one of the following:
Selenium
183
....... reduces the effect of adenosine
Aminophylline
184
Dyspnoea is a common side effect of
ticagrelor
185
Multifocal atrial tachycardia (MAT) is characterized by an irregular rhythm with at least three different P wave morphologies and is commonly associated with underlying pulmonary disease.
Calcium channel blockers like verapamil are the treatment of choice
186
Prinzmetal angina - treatment = dihydropyridine calcium channel blocker
Felodipine
187
How long is the half-life of this antiarrhythmic agent?
Amiodarone
Approximately 20-100 days
188
Which of the following conditions is least associated with coarctation of the aorta?
Prader-Willi syndrome
189
Supraventricular arrhythmias secondary to acute alcohol intake are well characterised and have been termed 'holiday heart syndrome'.
No specific treatment is required
190
Which one of the following is least associated with Wolff-Parkinson White syndrome?
Coarctation of the aorta
191
......................... is commonly associated with infective endocarditis amongst IVDU
Staphylococcus aureus
192
Which one of the following is least associated with myocarditis?
Leishmaniasis
193
ticagrelor moa
Reversibly binding with the platelet P2Y12 ADP receptor to prevent signal transduction
194
S4 coincides with the ............. on ECG
P wave
195
...................... isnt an indication for an implantable cardiac defibrillator
Wolff-Parkinson White syndrome
196
............. is least associated with mitral valve prolapse?
Acromegaly
197
. Once the ETT has begun, which one of the following is the strongest indication for stopping the test?
Blood pressure of 105/70 mmHg
198
Which one of the following is not a risk factor for statin-induced myopathy?
Large fall in LDL-cholesterol
199
B-type natriuretic peptide is mainly secreted by the
ventricular myocardium
200
ST-elevation myocardial infarction (STEMI), current guidelines recommend
dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor (preferably ticagrelor) for 12 months.
201
Which one of the following cardiac conditions is most associated with a louder murmur following the Valsalva manoeuvre?
Hypertrophic obstructive cardiomyopathy
202
Which one of the following features would indicate cardiac tamponade rather than constrictive pericarditis?
No Y descent on JVP
203
Which one of the following non-invasive methods provides the most accurate assessment of whether a patient has coronary artery disease?
Contrast enhanced cardiac CT
204
,............. is the most important cause of ventricular tachycardia (VT) clinically, followed by hypomagnesaemia.
Hypokalemia
205
................... is a centrally acting antihypertensive drug, which works by stimulating imidazoline receptors in the brain. This stimulation results in reduced sympathetic outflow from the central nervous system
Moxonidine
206
Warfarin - clotting factors affected mnemonic - 1972 (10, 9, 7, 2)
Factor XII is not affected by warfarin
207
Hypothermia characteristically causes prolongation of all ECG intervals, with the QT interval being particularly affected
spironolactone should be started if a patient's potassium is <4.5 mmol/L.
208
................... is the first line investigation for stable chest pain of suspected coronary artery disease aetiology
Contrast-enhanced CT coronary angiogram
209
Which one of the following statements regarding catecholaminergic polymorphic ventricular tachycardia (CPVT) is correct?
Symptoms generally develop before the age of 20 years
210
pregnancy is contraindicated
to statins
211
An ECG demonstrates T wave inversion and an epsilon wave in leads V1-V3.
Arrhythmogenic right ventricular cardiomyopathy is characterised by right ventricular myocardium replaced by fatty and fibrofatty tissue
212
warfarin be continued for at least ......... after successful cardioversion
4 weeks
213
An undersized blood pressure cuff may lead to an overestimation of blood pressure
Pulsus alternans - seen in left ventricular failure
214
hypertrophic obstructive cardiomyopathy which should be investigated with a
transthoracic echocardiogram
215
Taking simvastatin at night improves efficacy
Hypertension in diabetics - ACE inhibitors/A2RBs are first-line regardless of age
216
The waveform shows two systolic peaks and a normal dicrotic notch.
Mixed aortic valve disease
217
Bleeding on dabigatran?
Can use idarucizumab to reverse
218
According to DVLA guidelines, patients who have had a permanent pacemaker inserted must not drive for ..........following the procedure.
1 week
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