Cardiology MCQ Flashcards
(117 cards)
1
Q
A 52-year-old film director presents with a 45-minute history of aching chest pain and a heavy feeling in the left arm. The onset of the pain followed an important meeting where he was in dispute with the film producer. The patient appears anxious and uncomfortable but physical examination is otherwise unremarkable. Initial investigations showed 2–3mm ST elevation in leads V2, V3, V4 and V5 of the ECG but cardiac enzyme levels are normal.
The probable diagnosis is:
A. Unstable angina
B. Chest pain associated with anxiety
C. Gastro-oesophageal reflux
D. Acute anterior myocardial infarction
E. Acute posterior myocardial infarction
A
D. Acute anterior myocardial infarction
ST elevation must be MI (takes 4-6 hours for cardiac enzymes to elevate)
2
Q
A 25-year-old intravenous drug abuser, who has been injecting heroin for 5 years, presents with a one month history of anorexia, weight loss and bilateral ankle swelling. On examination he is slightly jaundiced with mild pitting ankle oedema and a temperature of 38.1°C. Auscultation of the heart reveals a soft pan-systolic murmur at the left sternal edge which is loudest on inspiration. The liver edge is tender and palpable two fingerbreadths below the right costal margin.
The most likely diagnosis is:
A. Heart failure associated with mitral valve disease
B. Aortic valve endocarditis
C. Tricuspid valve endocarditis
D. A ventriculoseptal defect
E. Hepatitis, anaemia and a flow murmur
A
C. Tricuspid valve endocarditis
Pansystolic murmur ddx (TR,MR, ASD)
RILE=right side increase on inspiration, left side increase on expiration
Increase on inspiration –> right side valvular problem + IVDU –> likely endocarditis
3
Q
A 23-year-old woman on “pills” for weight reduction presented with progressive onset of fatigue and shortness of breath. Physical examination showed a blood pressure of 110/80 mmHg, 8 cm distended neck vein with a prominent V wave. There is a loud P2 and a grade III pansystolic murmur over right sternal border. The most probable diagnosis is:
A. Mitral stenosis
B. Mitral valve prolapse
C. Primary pulmonary hypertension
D. Pulmonary stenosis
E. Hypertrophic cardiomyopathy
A
C. Primary pulmonary hypertension
Classical description of fenfluramine (an appetite suppressant) causing pulmonary arterial HT, which leads to RV failure and TR.
4
Q
Which of the following drugs prolongs QT interval?
A. Erythromycin
B. Ampicillin
C. Amikacin
D. Tetracycline
E. Vancomycin
A
A. Erythromycin
5
Q
Which one of the following conditions is an absolute contraindication for the use of thrombolytic therapy in patients with acute myocardial infarction?
A. Blood pressure 180/90 mmHg
B. Current use of anticoagulation with INR 2.0
C. Previous peptic ulcer
D. Recent hemorrhagic stroke
E. Surgical treatment for hernia 9 months ago
A
D. Recent hemorrhagic stroke
6
Q
A
A. Left ventricular dysfunction
7
Q
A
D. Cardiac amyloidosis
Restrictive cardiomyopathy causing low QRS voltage
8
Q
A
D. Angiotensin converting enzyme inhibitor
9
Q
Which of the following drugs can be used in in patients with Wolff-Parkinson-White syndrome that have atrial fibrillation? A. Digoxin B. Propranolol C. Diltiazem D. Verapamil E. Procainamide
A
E. Procainamide
In WPW with AF cannot use any AVN blockers at it will prevent an exit pathway for AF. Hence cannot use digoxin, B blocker and NDH CCB (verapamil, diltiazem)
10
Q
Which of the followings is not a complication of amiodarone? A. Photosensitivity B. Hypothyroidism C. Hyperthyroidism D. Torsades de pointes E. Antagonize the effect of warfarin
A
E. Antagonize the effect of warfarin
It inhibits CYP2C9, hence increases amount of warfarin.
11
Q
An old woman with SOB (?acute). One echocardiogram, there is poor filling. No abnormality found on P/E or ECG. Which is the most likely cause of her SOB?
A. Diastolic congestive heart failure
B. Systolic congestive heart failure
C. COPD
D. Asthma
A
A. Diastolic congestive heart failure
12
Q
When there is prolonged QT after quinine use, what is the most appropriate management? A. Increase the dose of quinine B. Stop the quinine and closely observe the patient C. Use procainamide
A
B. Stop the quinine and closely observe the patient
13
Q
A 31-year-old tall thin man complains of central chest pain, radiating to the back. He also has short- ness of breath. BP is low.
A. Pneumothorax
B. MI
C. Costochondritis
D. Saddle embolus
E. Dissecting thoracic aneurysm
A
E. Dissecting thoracic aneurysm
Trying to describe Marfan syndrome (tall thin man)
14
Q
ESM, normal HS. Faint 2 times already. BP 130/85 mmHg, pulse rate 80/min.
A. HCM
B. Mitral regurgitation
C. Mitral stenosis
D. Aortic sclerosis
E. Aortic valve stenosis
A
A. HCM
15
Q
A 68-year-old lady with history of angina, presents with BP of 170/115 mmHg. BP was 130/75 mmHg when she was 65 years old. Physical examination reveals bilateral carotid and femoral bruits. Renal function mildly impaired (creatinine 146). The most likely cause of her increased BP is:
A. Coarctation of aorta
B. Phaeochromocytoma
C. Conn’s syndrome
D. Renal artery stenosis
E. Idiopathic
A
D. Renal artery stenosis
Secondary hypertension caused by activation of RAAS (decreased GFR due to RAS causing increaased aldosterone secretion and reabsorption of Na+ and water –> increasing circulating pressure)
16
Q
A young adolescent presents with irregular pulse at 180/min. After injection of digoxin to slow down the heart rate, go into VF. Which would be the abnormality ECG on admission?
A. Sinus tachycardia
B. Atrial flutter
C. Atrial fibrillation with wide QRS complex
D. Atrial fibrillation E. PSVT
A
C. Atrial fibrillation with wide QRS complex
wide QRS complex (short PR interval –> WPW type B left sided pathway)
AFib –> with blocking of AVN causes no exit route –> inducing VFib
17
Q
65/M. Palpitation. AF. Given verapamil can spontaneously revert to sinus rhythm. 48 hours later, he repeated paroxysmal AF. Which is the best treatment to prevent further AF?
A. Amiodarone
B. Sotalol
C. Verapamil
D. Flecainide
E. Digoxin
A
A. Amiodarone
18
Q
Which of the followings improve survival of systolic heart failure? A. Digoxin B. Flecainide C. Frusemide D. Nifedipine E. Metoprolol
A
E. Metoprolol
19
Q
80/F chronic hypertension, on diltiazem. Also on enteric coated aspirin, calcium and vitamin D supplement. Friend died recently and she felt very depressed afterwards. Feel better after taking herbal medicine for 1 month. P/E: BP 152/106 (3 months ago 130/82). Laboratory investigations: normal. What is the likely cause of her hypertension?
A. White coat hypertension
B. Diltiazem interact with herbal medicine
C. Diltiazem interact with calcium
D. Renal failure
E. Depression
A
B. Diltiazem interact with herbal medicine
20
Q
Elderly with DM + HT, BP ?230/160 mmHg. Drowsy. Hypertensive retinopathy grade III. CT brain normal. Family admitted that she did not take antihypertensives for a week. What is your management? A. Observe B. Wait till blood result come back C. IV diazepoxide D. IV sodium nitroprusside E. IV nifedipine
A
D. IV sodium nitroprusside
1st line management of malignant hypertension
21
Q
An elderly lady, anorexia, palpitation for ?1 week, fell 3 times, found AF 110/min. Which of the following is the likely cause? A. BP 170/95 mmHg B. Echo showing mitral regurgitation C. TSH < 0.1
A
C. TSH < 0.1
22
Q
Which of the following is correct concerning the physiology of right ventricle? A. Diastolic inflow increases with inspiration B. Ejection systolic volume is less than left ventricle C. End systolic pressure is typically < 60 mmHg D. Compliance is less than that of the left ventricle E. Simultaneous end-systole with left ventricle
A
A. Diastolic inflow increases with inspiration
RILE (right sided murmurs increase in inspiration, left sided murmurs on expiration)
During inspiration there is negative intrathoracic pressure which produces a pressure gradient which drives more blood from the right atrium
23
Q
Apart from ST concave elevation, which of the following feature is suggestive of acute pericarditis? A. ST depression B. PR depression C. Diffuse ST elevation + T inversion D. Normal CPK level E. S3 gallop
A
C. Diffuse ST elevation + T inversion
24
Q
78/M, presented with ST elevated anterior myocardial infarction, treated with streptokinase, aspirin, beta-blocker and ACEI. 4 days after, he presented with angina and acute SOB. BP 120/80 mmHg, pulse 130 and there is a newly detected pan-systolic murmur. What is the management of this patient?
A. Emergency cardiac catheterization with coronary angioplasty
B. IV heparin
C. IV heparin + frusemide
D. IV heparin + tPA
E. IV nitroprusside
A
E. IV nitroprusside
D/dx incl VSD vs MR. Septal rupture usu cause RV failure, while MR cause LV failure. In either case, vasodilator is useful to reduce afterload.
A, B, C, D – these are more for re-infarction
25
An elderly woman, with a history of hypertension, currently on diltiazem and atenolol, is admitted for lightheadedness. Heart rate 40/min, with some temporary pauses of 2–3 sec. BP 90/40 mmHg. What is the management?
A. External pacing now, arrange implantation of permanent pacer this afternoon
B. External pacing now, stop diltiazem and atenolol
C. Insert guidewire for biventricular pacing
D. Stop diltiazem and arrange electrophysiological study
E. Go directly to implantation of permanent pacer
B. External pacing now, stop diltiazem and atenolol
Haemodynamically unstasble --> requires pacing first
26
A 23-year-old male presented with recent episode of exercise induced dyspnoea. PE found grade 3/6 systolic murmur at left sternal border. ECG showed Q wave at apical and lateral and left ventricular hypertrophy. Echocardiogram showed asymmetrical septal hypertrophy with no obstruction. Which of the following statements is correct?
A. Family history is not significant
B. Risk of sudden death is low
C. Use of calcium channel blocker can improve symptoms
D. The symptoms are due to lateral infarction
E. Histology should show normal finding except infarction changes
C. Use of calcium channel blocker can improve symptoms
-ve inotropic agents, e.g. BB, non-dipine CCB are 1st line treatment for HCMP.
27
Concerning long-acting nitrate preparation:
A. Tolerance may develop
B. Effects can be counteracted by highly selective beta-2 antagonist
C. More flushing by transdermal preparation
D. Sublingual preparation is more effective than transdermal
E. Maximum dose of isosorbide is 15 mg q3–4h
A. Tolerance may develop
Long-acting (e.g. isosorbide dinitrate) or transdermal preparations are continuous therapy, give rise to tolerance. (in contrast to intermittent therapy e.g. nitroglycerin)
28
Which of the following is most true of calcium channel blocker?
A. Facial flushing is a common side effect
B. It causes cold feet and hands in winter
C. It causes diarrhoea
D. It improves peripheral oedema in patient with congestive heart failure
E. It is positively inotropic and increases cardiac contractility
A. Facial flushing is a common side effect
29
Which of the following antihypertensive drugs can cause glucose intolerance? A. ACEI B. ARB C. CCB D. Thiazide E. Methyldopa
D. Thiazide
30
A 67-year-old man presents with dizziness and fainting for several months. MI and drug-induced causes have been ruled out already. ECG shows regular p wave, while QRS once every 3 beats p wave. What is the treatment? A. Pacemaker B. IV digoxin C. IV isopro(?) D. IV atropine E. No need treatment as its benign
A. Pacemaker
31
Which of the following are ECG changes of digoxin intoxication? A. ST depression B. T wave inversion C. Atrial flutter D. Atrial tachycardia with variable block E. PR prolongation
D. Atrial tachycardia with variable block
Note that digoxin toxicity ≠ digoxin effect. A, B, E – these are digoxin effects, i.e. happen at normal physiological dose
32
Which of the following abused substance causes myocardial infarction? A. Cocaine B. Marijuana C. Alcohol D. Opioids E. Benzodiazepines
A. Cocaine
33
Which is not an indication for surgical intervention in treatment of IE? A. Large left sided vegetation with systemic embolism B. Heart failure due to valve damage C. Abscess formation D. Failure of antibiotic therapy E. Pulmonary embolism due to right sided endocarditis
E. Pulmonary embolism due to right sided endocarditis
Indications of surgery in IE:
* Heart failure due to valve dysfunction
* Paravalvular extension: abscess, fistula, ± heart block
* Difficult-to-treat pathogen e.g. fungal or other highly resistant organisms
* Persistent bacteraemia after exclusion of other causes
* Recurrent embolization with persistent vegetation despite Abx
34
Which of the followings does not cause aortic regurgitation?
A. Ankylosing spondylitis
B. Syphilis
C. Severe mitral stenosis
D. Bicuspid aortic valve
E. Aortic dissection
C. Severe mitral stenosis
35
A 70/M presented with syncope. P/E showed slow rising pulse. BP 110/70, 5/6 ESM at aortic area with radiation to the neck. ECG showed a 58 bpm sinus rhythm, PR 200 ms and left ventricular hypertrophy. What would be your management for this patient?
A. Pacemaker
B. Surgical closure of VSD
C. Aortic valve replacement
D. Mitral valve repair
E. Pulmonary vein replacement
C. Aortic valve replacement
aortic stenosis requires replacement if severe
36
Which class of drugs can improve prognosis in patients presenting with heart failure with left ventricular ejection function <25%?
A. Class 1c antiarrhythmic drug
B. Thiazides
C. Calcium channel blocker
D. Angiotensin receptor blocker
E. Digoxin
D. Angiotensin receptor blocker
37
24/F, history of taking weight losing drug. Now complains of progressive SOB. PE shows parasternal heave, loud P2. What is the appropriate management?
A. Beta blocker
B. Sildenafil
B. Sildenafil
38
18/M collapsed after soccer game. Certified dead on arrival at AED. What is the most likely autopsy finding? A. Normal B. (Some kind of abnormality in RCA) C. Hypertrophic cardiomyopathy D. Mitral valve prolapse
C. Hypertrophic cardiomyopathy
39
In STEMI, angioplasty is better than fibrinolysis when: A. Cardiogenic shock B. Acute mitral regurgitation C. Acute aortic dissection D. Cardiac perforation E. Left ventricular thrombus
A. Cardiogenic shock
Scenarios where only PCI should be done incl:
* Diagnosis in doubt → verify diagnosis by coro/PCI
* High bleeding risk → thrombolytic C/I
* Cardiogenic shock or unstable hemodynamic → benefit of PCI > thrombolytics
40
A 65-year-old Indian lady was brought to the A&E department by her family members. She was found to be lethargic over the past few months and become more unwillingly to get off the bed. She complained of constipation, other than that there was no other specific symptom. She had hypertension for 10 years and was put on atenolol. She also had depression and was on citalopram. On admission, a nurse reported the following vital signs to you: BP 90/65 mmHg, heart rate 62 bpm, body temperature 30.2°C. Which of the following is the most likely diagnosis?
A. Atenolol overdose
B. Hypothyroidism
C. Myocardial infarction
D. Stroke
E. Citalopram toxicity
A. Atenolol overdose
41
18/F with heart rate 150 bpm. Returned to sinus rhythm after administration of adenosine triphosphate. What is the most likely diagnosis? A. Atrioventricular nodal reentry tachycardia B. Atrial fibrillation with rapid ventricular response C. Sinus tachycardia D. Ventricular tachycardia E. Atrial flutter with 2:1 block
A. Atrioventricular nodal reentry tachycardia (has parasympathetic input)
42
78/F, long history of hypertension, complained of sudden onset of dyspnoea. Cardiovascular exam normal except prominent precordial apex. CXR showed pulmonary congestion without cardiomegaly. Exercise thallium scan did not show ischaemic changes. Echocardiogram showed normal left and right ventricular function with left ventricular hypertrophy. Which of the following best explain her dyspnoea?
A. Chronic obstructive pulmonary disease
B. Late onset asthma
C. Ischaemic heart disease
D. Diastolic heart failure
E. Systolic heart failure
D. Diastolic heart failure
43
Which of the following is the commonest inheritable cardiovascular disease? A. Arrhythmogenic right ventricular dysplasia B. Dilated cardiomyopathy C. Hypertrophic cardiomyopathy D. Long QT syndrome E. Restrictive cardiomyopathy
C. Hypertrophic cardiomyopathy
44
Which of the followings is the strongest risk factor for cardioembolic stroke in a patient with atrial fibrillation? A. Aortic stenosis B. Mitral stenosis C. Prior history of stroke D. Hypertension E. Age > 75
B. Mitral stenosis
Valvular heart ds (esp MS) carries a much higher risk of embolism, hence anti-coag is always indicated regardless of CHADVASc score
45
Which of the followings is an absolute contraindication for fibrinolytic in patient with STEMI?
A. Suspected aortic dissection
B. On warfarin
C. Early presentation
A. Suspected aortic dissection
46
70/M, unconscious after climbing few steps, SOB, chest pain, BP 130/95, pulse 80/min regular, ESM radiate to neck, heart sounds are normal. What is the diagnosis?
A. Dilated cardiomyopathy
B. MR
C. MS
D. Aortic sclerosis
E. Aortic stenosis
D. Aortic sclerosis
47
To differentiate between epilepsy and syncope, which of the following finding after the patient wakes up makes a syncope picture more likely?
A. Oriented and alert
B. Disoriented and drowsy
C. Urinary incontinence
D. Bite marks on the tongue
E. Uprolling eyeball
A. Oriented and alert
48
Which of the followings is a factor to be considered in risk stratification of stroke prevention in patients having atrial fibrillation? A. Age < 65 B. Hyperlipidaemia C. Hypertension D. Mitral valve prolapse E. Smoking
C. Hypertension
49
Which of the following patients need antibiotic prophylaxis for dental extraction for prevention of infective endocarditis?
A. 15-year-old child with ASD
B. Young female with MVP
C. Woman with mitral valve replacement with prosthetic heart valve
D. Man with mild aortic stenosis
E. Old lady with a pacemaker
C. Woman with mitral valve replacement with prosthetic heart valve
50
A 65-year-old female with history of breast cancer present with dizziness. On examination her blood pressure is 90/50. There was elevated jugular venous pressure which was more markedly increased during inspiration. The heart sounds were distant. Which of the following is the most likely diagnosis? A. Aortic dissection B. Cardiac tamponade C. Congestive heart failure D. Pulmonary embolism E. Severe tricuspid regurgitation
B. Cardiac tamponade
Cardiogenic shock causing hypotension
51
A 50-year-old gentleman was admitted with retrosternal chest discomfort with ECG showing ST elevations consistent with acute anterior myocardial infarction. Three days later, he developed severe shortness of breath without any chest pain. A new pan-systolic murmur with thrill was detected at the left lower sternal border. Which of the following is the most likely diagnosis?
A. Acute mitral regurgitation due to rupture of chordae tendineae
B. Acute pulmonary embolism
C. Left ventricular free wall rupture
D. Post-myocardial infarct ventricular septal defect
E. Tricuspid regurgitation due to papillary muscle dysfunction
D. Post-myocardial infarct ventricular septal defect
52
58/M, presenting with syncope on exertion. He reported to the paramedics that before the syncope, he experienced chest pain and shortness of breath. On physical examination, the pulse is 80, regular; blood pressure is 130/80 mmHg. Precordial examination reveals an ejection systolic murmur radiating to bilateral carotids. A. Aortic sclerosis
B. Aortic valvular stenosis
C. Aortic valvular incompetence
D. Hypertrophic cardiomyopathy
E. MVP
A. Aortic sclerosis
53
A 56-year-old obese man presents with chest pain. A contrast CT scan confirmed type B aortic dissection. Which of the following is the appropriate first-line class of drug to use in order to lower his blood pressure?
A. Angiotensin converting enzyme inhibitors
B. Beta blockers
C. Diuretics
D. Hydralazine
E. Calcium channel blockers
B. Beta blockers
Therapeutic goal: reduction of systolic BP to 100-120mmHg, and target HR of 60-70/min
IV labetolol (lowers the HR and BP)
IV sodium nitroprusside (caution in patients with renal impairment, limit infusion rate to <3mg/kg/min if eGFR <30ml/min/1.73m2) Nitroprusside not used if HR not controlled as vasodilation can lead to reflex tachycardia
Diltiazem and verapamil are acceptable alternatives when BB are contraindicated (COAD)
54
Which of the following antibiotics will prolong the QTc interval? A. Azithromycin B. Cefuroxime C. Clindamycin D. Penicillin E. Vancomycin
A. Azithromycin
55
Which of the following is pathognomonic for ventricular tachycardia?
A. Atrio-ventricular dissociation
B. Captured beats
C. Extreme axis deviation
D. Left bundle branch block morphology
E. Wide QRS complex with rate of 160 bpm
B. Captured beats
56
A 70-year-old lady, fragile (body weight 40 kg), ECG shows atrial fibrillation with rapid ventricular rate. There were no thyroid signs including insomnia, palpitation, tremor, eye signs, goitre. She was treated with digoxin at 0.125 mg/day. Weeks later she developed anorexia, nausea and diarrhoea, while ventricular rate remained high. Which of the following concerning the diagnosis and management is TRUE?
A. Likely to improve by adding amiodarone
B. Lone AF is the likely diagnosis
C. Hyperthyroidism has been ruled out
D. Dose of digoxin given is appropriate
E. Checking of serum level of digoxin with an appropriately collected blood sample would help to elucidate the cause of some of the above symptoms
C. Hyperthyroidism has been ruled out
57
Young girl/woman kneeling on the floor having her hair styled. Felt hot and fidget. Told to remain still. Fell forward onto a sofa, remained semi-upright. Noted to have bilateral upper limb twitching for a few seconds. Regained consciousness immediately. ECG normal. What is the diagnosis? A. Cardiogenic syncope B. General tonic-clonic seizure C. Non-epileptic attack disorder D. Postural hypotension E. Vasovagal syncope
E. Vasovagal syncope
58
A 74-year-old woman presented with breathlessness of sudden onset. On examination, her pulse was 115 beats per minute and her blood pressure was 160/70 mmHg. Investigations: Chest X-ray: pulmonary oedema What is the most appropriate initial treatment goal?
A. Block sympathetic activity
B. Improve contractility
C. Improve coronary perfusion pressure
D. Reduce preload
E. Reduce pulse
D. Reduce preload
59
A 20-year-old waitress presents with progressive shortness of breath on exertion. She previously was on medications for weight reduction. Physical examination showed parasternal heave and loud P2. Chest X-ray did not show pulmonary congestion. What is the appropriate next step of investigation?
A. Echocardiogram
B. Spirometry
C. 24-hour urine catecholamine
D. Ambulatory blood pressure monitoring
E. ABG
A. Echocardiogram
60
50/M with chest pain and other acute coronary syndrome symptoms at 9 am. He attended the A&E department at 1 pm. He has been prescribed aspirin and clopidogrel and is now admitted into cardiology ward. ECG shows ST segment depression and T wave inversion. Troponin increased. What would you prescribe him? A. Heparin B. TPA C. Primary PCI D. Streptokinase E. Warfarin
A. Heparin
NSTEMI: aspirin, clopidogrel, unfractionated heparin or LMWH, IV platelet glycoprotein 2b/3a complex blockers (tirofiban, eptifibatide)
Unstable angina/NSTEMI management
Anti thrombotic therapy: aspirin + clopidogrel +LMWH
Antiischemic therapy: nitrates (sublingual TNG), B blockers (metoprolol: Betaloc if not contraindicated), calcium antagonist (when BB contraindicated --> diltiazem, verapamil)
Other therapies: statin given regardless of baseline LDL-C, ACEI (within first 24 hours in the absence of hypotension/contraindications)
High risk factors to consider early PCI
* Ongoing or recurrent rest pain
* Hypotension and APO
* Ventricular arrhythmia
* ST segment changes >0.1mV; new bundle branch block
* Elevated troponin >0.1mg/mL
* High risk score (TIMI, GRACE)
61
A 55-year-old gentleman presents to the Emergency Department with breathlessness, chest pain and haemoptysis. He just returned from America this morning from a trip to his son’s graduation. On physical examination, his pulse rate is 110/min and his blood pressure is 100/60mmHg. His jugular venous pressure is elevated. The pulse oximetry is 91%. On auscultation, bilateral chest are unremarkable. ECG shows sinus tachycardia and right axis deviation. What is the most appropriate investigation to be done? A. Arterial blood gas B. Chest x-ray C. CT pulmonary angiogram D. Coronary angiogram and percutaneous coronary intervention E. Echocardiogram
C. CT pulmonary angiogram
62
70/M type 2 DM with headache, HR 50/min, BP 160/100 mmHg, bilateral renal bruit. Which drug should be used to control hypertension? A. Amlodipine B. Captopril C. Losartan D. Metoprolol E. Verapamil
A. Amlodopine (CCB)
B, C – should not be given in the presence of bilateral RAS
D, E – should not be given in the presence of bradycardia
1st line management of hypertension normaly: ACE/ARB + CCB (DHP has antihypertensive effect: nifedipine/amlodopine in comparison to non DHP: verapamil/diltiazem (antiarrhythmic effect)/diuretic
63
78/F with history of chronic hypertension presents with SOB. ECG shows features compatible with left ventricular hypertrophy. CXR shows normal cardiothoracic ratio and pulmonary oedema. What is your diagnosis?
A. Cor pulmonale
B. Diastolic heart failure
C. Dilated cardiomyopathy
D. Hypertrophic cardiomyopathy
E. Left ventricular aneurysm
B. Diastolic heart failure
64
Which drug reduce risk of death for long QT syndrome? A. Amiodarone B. Atenolol C. Diltiazem D. Flecainide E. Sotalol
B. Atenolol
65
Which one is the most useful investigation to diagnose early MI? A. CK-MB B. ECG C. Troponin D. Coronary angiography E. Echocardiogram
E. Echocardiogram
66
50/M presented with chest pain with radiation to back. BP on right arm 190/120 mmHg, BP on right leg 110/80 mmHg. ECG shows 2 mm STE in leads II, III, aVF. What is the likely cause?
A. Aortic dissection
B. Acute inferior MI
C. Acute posterior MI
D. Coarctation of aorta
E. Pulmonary embolism
A. Aortic dissection
67
Digoxin increases myocardial contractility PRIMARILY by: A. Inhibit Na-K-ATPase B. Open calcium channel C. Release calcium from sarcoplasmic reticulum D. Stimulate membrane phospholipase C E. Stimulate myosin ATPase
A. Inhibit Na-K-ATPase
Digoxin exert its inotropic effect by inhibiting Na/K/ATPase → ↓Na channel activity → ↑intracellular Ca.
68
Old lady after breakfast. Sitting on chair. LOC for 1 minute. Regain consciousness and found herself on the floor. Mild pain on both legs. There was no witness. Most likely cause? A. Cardiogenic syncope B. Stroke C. Epileptic seizure D. Hypoglycemia E. TIA
A. Cardiogenic syncope
69
Which of the following is true for exercise ECG?
A. Thallium-201 scan has higher sensitivity and specificity
B. Decrease time before SOB is not associated with shorter lifespan
C. Interpretation of the exercise ECG is not affected by baseline abnormalities like LBBB or LVH
D. Drop in blood pressure suggests poor conditioning and is not associated with adverse CVS events
E. Increase the cutoff from 1 mV to 2 mV increases sensitivity of the test
A. Thallium-201 scan has higher sensitivity and specificity
70
All of the followings are typical radiographic signs of left ventricular failure, except:
A. Bilateral symmetrical pleural effusions
B. Flattened hemidiaphragms
C. Increased cardiothoracic ratio >0.5 on a postero-anterior chest x-ray
D. Interstitial oedema
E. Presence of Kerley B lines
B. Flattened hemidiaphragms
71
Which of the following factors is to be taken into consideration in stroke risk stratification in atrial fibrillation? A. Age <65 B. Heart failure C. Hyperlipidemia D. Mitral regurgitation E. Obesity
B. Heart failure
CHADSVAS2 score
congestive heart failure, hypertesion, age>75, DM, previous stroke, TIA
Vascular disease, age 65-74 years, sex category (female)
72
Which of the following beta-blockers has no benefit in patients with heart failure? A. Bisoprolol B. Carvedilol C. Metoprolol D. Nebivolol E. Sotalol
E. Sotalol
73
The following have left ventricular hypertrophy except A. Hypertrophic obstructive cardiomyopathy B. Mitral stenosis C. Aortic stenosis D. Systemic hypertension E. Coarctation of aorta
B. Mitral stenosis
74
Which one heaving apex? A. Aortic regurgitation B. Aortic stenosis C. Mitral regurgitation D. Mitral stenosis with pulmonary hypertension E. Mitral stenosis without pulmonary hypertension
B. Aortic stenosis
Causing left ventricular hypertrophy
Thrusting apex: mitral or aortic regurgitation (volume overload causing dilatation)
Tapping apex: mitral stenosis
75
A man with bilateral limb swelling, and abdominal distension. Examination found 3+ edema, with ascites and raised jugular venous pressure, which moves up with inspiration. Which of the following is the most likely diagnosis?
A. Heart failure
B. Cirrhosis
C. Constrictive pericarditis
D. Complete heart block
E. Nephrotic syndrome
C. Constrictive pericarditis
76
A 60-year-old male was admitted because of severe chest pain radiating to the back. His blood pressure was 200/120 mmHg. Chest X-ray showed widening of mediastinum. Computed tomography revealed aortic dissection involving the descending thoracic aorta only. Which of the following is the treatment of choice?
A. Immediate surgical repair
B. Medical treatment with aspirin followed by surgical treatment
C. Medical treatment with intravenous labetalol and nitroprusside D. Medical treatment with labetalol and nitroprusside followed by surgical repair
E. Urgent aortic stenting
C. Medical treatment with intravenous labetalol and nitroprusside
Careful with rate of admin of nitroprusside in reduced eGFR (<30mmol)
77
A 21-year-old woman complained of on and off fast palpitations, which occurred suddenly. The palpitations usually stopped after coughing. Electrocardiography showed sinus rhythm, short PR-interval, and tall R waves in V1. What is the most likely diagnosis? A. Atrio-ventricular nodal entry tachycardia
B. Heart failure
C. Hyperthyroidism
D. Pulmonary hypertension
E. Wolff-Parkinson-White syndrome
E. Wolff-Parkinson-White syndrome
Tall R wave in V1 only has 4ddx
Posterior MI, WPW, RBBB and RVH
Resting ECG of a patient with a history of but not active AVNRT, will have no difference from normal
78
A 25-year-old woman complained of chest pain for 2 days. Electrocardiography showed sinus tachycardia, and ST segment elevation over anterior, lateral and inferior leads. What is the most likely diagnosis? A. Acute aortic dissection B. Acute pericarditis C. Acute ST segment elevation myocardial infarction D. Pulmonary embolism E. Takusubo cardiomyopathy
B. Acute pericarditis
79
A 60-year-old male with known history of poorly controlled hypertension was admitted because of sudden unprovoked severe back pain with high blood pressure (200/120 mmHg) at 11:00 pm. Chest X-ray showed mild cardiomegaly. Which of the following investigations would you order for the suspected diagnosis? A. Computed tomography without contrast B. Elective computed tomography with contrast C. Magnetic resonance imaging with contrast D. Magnetic resonance imaging without contrast E. Urgent computed tomography of thorax with contrast
B. Elective computed tomography with contrast
80
A 35-year-old man presents with fever and physical examination reveals a loud pansystolic murmur grade 4/6 which is best heard at the apex and which radiates to the axilla. Echocardiogram shows vegetation over the mitral valve. Which of the following type of microorganism is the most likely cause of his infective endocarditis? A. Bartonella B. Cardiobacterium C. Chlamydia D. Coxiella burnetiid E. Streptococcus viridans
E. Streptococcus viridans
81
A 55-year-old hypertensive man complained of chest pain of sudden onset for 2 hours. Electrocardiography showed sinus tachycardia, tall R waves in V1 and V2, and 1mm ST segment depression over V1 and V2. What is the most likely diagnosis? A. Acute aortic dissection B. Acute posterior wall myocardial infarction C. Non-ST segment elevation myocardial infarction D. Pulmonary embolism E. Takusubo cardiomyopathy
B. Acute posterior wall myocardial infarction
82
A 50-year-old man was admitted with severe chest pain after strenuous exercise at 9:00am. The patient attended the Accident and Emergency Department at 1:00 pm. ECG showed ST depression with T wave inversion over V3-V6. Troponin level was elevated. He was given aspirin and clopidogrel and transferred to the cardiac ward for further management. Which of the following treatment should be given? A. Low molecular weight heparin B. Primary percutaneous coronary intervention C. Streptokinase D. Tissue plasminogen activator E. Warfarin
A. Low molecular weight heparin
83
A 58-year-old man with history of hypertension and diabetes on medications He presents with on and off palpitation for 2 months. Physical examination showed irregularly irregular pulse and his blood pressure is 128/85 mm Hg. ECG showed atrial fibrillation with ventricular rate 80 bpm. Which of the following treatment can reduce the risk of stroke in this patient? A. Amiodarone B. Digoxin C. Diltiazem D. Immediate electrical cardioversion E. Warfarin
E. Warfarin (or NOAC)
84
Which of the following is the pathognomonic feature of ventricular tachycardia? A. Atrial-ventricular dissociation B. Deviated axis C. RBBB D. LBBB E. Wide complex tachycardia >160 bpm
A. Atrial-ventricular dissociation
Regular wide complex tachycardia the ddx would be VT vs SVT with aberrent conduction. The most useful features are independent A/V activity i.e. AV dissociation, fusion beat, capture beat etc.
B,C,D,E are suggestive of VT, but non are proof of VT
85
Which of the following is most predictive of stroke in patients with non valvular AF? A. Age 65-75 B. TIA C. Hypertension D. Hyperlipidemia E. mitral regurgitation
B. TIA
Only age >75 is the other factor that has a score of 2
86
A 27-year-old woman presents with chest pain and progressive shortness of breath for 2 weeks. Physical examination shows a blood pressure of 90/40mmHg, 8 cm distended neck vein with pulsus paradoxus and bilateral ankle edema. Her heart sounds are soft and no murmur is detected. ECG shows diffuse low voltage over all the ECG leads. What is the most likely clinical diagnosis for this patient? A. Acute pericarditis B. Aortic stenosis C. Hypertrophic cardiomyopathy D. Mitral stenosis E. Primary pulmonary hypertension
A. Acute pericarditis
87
36 year-old lady with SLE presented with recurrent syncope. ECG shows RAD and tall R wave in V1. What is the most likely diagnosis? A. Pulmonary hypertension B. Vasovagal syncope C. Pericarditis D. Heart failure
A. Pulmonary hypertension
88
IV drug user, which of the following valve is most commonly involved in infection? A. Aortic root B. Aortic valve C. Mitral valve D. Pulmonary valve E. Tricuspid valve
E. Tricuspid valve
89
A 22-year-old lady presents with recurrent syncope and diagnosed to suffer from vasovagal syncope on tilt table test. She fails to control her symptom with non-pharmacological intervention. Which of the following agent can be used to reduce symptom in this patient? A. Beta-blocker B. Captopril C. Diuretic D. Diltiazem E. Midodrine
E. Midodrine
alpha1 adrenergic agonist that is the most effective drug for vasovagal syncope
Non pharmacological treatment: increase Na+ intake for volume expansion. Physical counterpressure manouvres, permanent pacemaker implantation
90
AMI, ST depression with T wave inversion on II, III aVF, cardiac enzymes elevated, AMI 5 hours ago admitted to CCU. What will you give? A. Aspirin only B. Aspirin + CCB C. Aspirin + nitrates D. Aspirin + ticagrelor E. Ticagrelor only
D. Aspirin + ticagrelor
91
IE after dental extraction, on echocardiogram there is an oscillating mass. Most likely organism? A. Staphylococcus aureus B. Enterococcus C. Viridans Streptococci D. Streptococcus suis E. E Coli
C. Viridans Streptococci
92
Which of the following clinical findings is MOST predictive of critical aortic valvular stenosis?
A. Increased aortic valve area
B. Increased aorto-ventricular pressure gradient
C. Increased pulse pressure
D. Loud systolic ejection murmur
E. Weak pulses with a delayed peak
B. Increased aorto-ventricular pressure gradient
93
Which of the following is the most common pathophysiologic mechanism triggering ST elevation myocardial infarction? A. Coronary plaque erosion B. Coronary plaque progression resulting in complete occlusion C. Coronary plaque rupture D. Coronary spasm E. Coronary thrombus formation
C. Coronary plaque rupture
94
A 65-year-old man presented with chest pain and dyspnoea on exertion. Physical examination showed a slow rising pulse and an ejection systolic murmur over the aortic area with radiation to neck. An ECG showed sinus rhythm with left ventricular hypertrophy. What is the most likely clinical diagnosis for this patient? A. Aortic regurgitation B. Aortic stenosis C. Eisenmenger’s syndrome D. Mitral valve prolapse with mitral regurgitation E. Primary pulmonary hypertension
B. Aortic stenosis
95
What is the necessary treatment for stroke prevention in patients with underlying mechanical mitral valve replacement? A. Aspirin B. Aspirin and clopidogrel C. Aspirin and warfarin D. Dabigatran E. Warfarin
E. Warfarin
96
A. Amlodopine
97
A 30-year-old male was admitted because of persistent fever (>38 °C) for 2 weeks. He was a known intravenous drug addict. Echocardiogram showed an oscillating mass over the tricuspid valve. Which of the following would be the most likely microorganism that contributed to his condition? A. Candida albicans B. Coxiella C. Enterococcus D. Staphylococcus aureus E. Streptococcus viridens
D. Staphylococcus aureus
98
Young man, SOB, CT pulmonary angiogram shown PE. Indication for thrombolytic therapy: A. S1Q3T3 B. Sinus tachycardia C. Troponin rise D. Hypotension E. Persistent pain
D. Hypotension
99
E. Transvenous pacing
As patient has complete heart block it requires transvenous pacing (transcutaneous pacing if urgent)
100
A 76-year-old lady presented with on and off palpitation. An ECG showed atrial fibrillation with ventricular rate of 78 bpm. Which of the following is a contraindication to the use of direct Xa inhibitor for stroke prevention in this patient? A. Body weight of 45 kg B. Presence of mechanical prosthetic heart valve C. Presence of moderate aortic stenosis D. Prior history of bleeding gastric ulcer E. Renal impairment with creatinine clearance 30 mL/min
E. Renal impairment with creatinine clearance 30 mL/min
Direct anticoagulants (direc thrombin inhibitors (dabigatran), direct factor Xa inhibitors (rivaroxaban, apixaban)) are not used in the following conditions
* Patients with AF and mechanical heart valves due to excessive thromoembolic and bleeding events
* Not recommended in patients with AF and ESRF or on dialysis due to lack of evidence from clinical trials regarding the balance of risk and benefits
* Not recommended in pregnancy: lack of information on efficacy and fetal safety
101
A 37 years old pregnant lady is admitted to Emergency Department at 36 gestational weeks for severe headache and ankle edema. Her blood pressure is 220/130 mm Hg. What is the first line treatment for her condition? A. Captopril B. Labetalol C. Losartan D. Nitroprusside E. Spironolactone
B. Labetalol
102
75/M acute chest pain for 1 hour. ECG shows STE on V1-5. Which is an absolute contraindication of thrombolytic therapy? A. Elevated BP 160/100 B. Bleeding peptic ulcer 6 months ago C. Cataract surgery 3 weeks ago D. Ischemic stroke 2 weeks ago E. Treatment with warfarin
D. Ischemic stroke 2 weeks ago
103
STEMI. Which of the following is correct? A. Aspirin and clopidogrel should not be used together B. Cardiac enzyme should be checked first before commencing reperfusion therapy C. Aspirin should not be used before cardiac enzymes confirm diagnosis. D. Percutaneous coronary intervention is better than thrombolytic after 3 hours of onset E. Reperfusion can be delayed for 24 hours
D. Percutaneous coronary intervention is better than thrombolytic after 3 hours of onset
104
A 70-year-old woman with type II diabetes presented with headache. Physical examination showed her heart rate was 50 bpm, blood pressure 160/100 mmHg and bilateral renal bruit. Which of the following is the most appropriate initial drug therapy for the treatment of her high blood pressure? A. Amlodipine B. Captopril C. Losartan D. Metoprolol E. Verapamil
A. Amlodipine
105
A 27-year-old woman presents with progressive onset of fatigue and shortness of breath. Physical examination shows a blood pressure of 90/40 mmHg, 8 cm distended neck vein with a prominent V wave. There is a loud P2 and a grade III pansystolic murmur over right sternal border. What is the most likely diagnosis? A. Acute pericarditis B. Aortic stenosis C. Hypertrophic cardiomyopathy D. Mitral stenosis E. Primary pulmonary hypertension
E. Primary pulmonary hypertension
106
A 77-year-old woman has had anorexia, breathlessness, and palpitations for several months. She has difficulty in climbing up stairs and has fallen three times previously. Electrocardiogram shows atrial fibrillation at a rate of 110 per minute. Which of the following findings suggests a cause for the arrhythmia? A. Atrial fibrillation and nonspecific ST-T wave changes on repeat electrocardiogram B. Blood pressure 170/95 mmHg C. Mild mitral regurgitation on echocardiogram D. Serum sodium of 128 mmol/L E. Serum TSH level <0.1 mIU/L
E. Serum TSH level <0.1 mIU/L
107
A 55-year-old man presents with increasing shortness of breath over a three week period. He drinks up to 10 pints of beer on Friday nights, and 5 pints the rest of the week. He has noticed his heart fluttering, and on examination he is in atrial fibrillation at a rate of 160 bpm. Which of the following vitamin deficiency is likely to contribute to his myocardial disease? A. Ascorbic acid (vitamin C) B. Hydroxocobalamin (vitamin B12) C. Pyridoxine (vitamin B6) D. Retinoic acid (vitamin A) E. Thiamine (vitamin B1)
E. Thiamine (vitamin B1)
BeriBeri
108
Patient on ARB. poorly controlled HT despite increase in dose of ARB. Which drug is likely the cause? A. Fluconazole B. Erythromycin C. Acetaminophen D. MAOI
A. Fluconazole
Fluconazole (Diflucan) is a potent CYP2C9 inhibitor, impairing the conversion of losartan (Cozaar) to its active form.
109
60/F, chronic rheumatic heart disease, atrial fibrillation, with AV replacement, mechanical valve. Which would be the appropriate choice for anticoagulation to prevent future thromboembolic events? A. Warfarin B. Aspirin C. Rivaroxaban
A. Warfarin
110
Old man with recurrent syncope. PR slightly prolonged, missed one beat every 3 beats. Regular P. Treatment? A. IV Atropine B. IV Isoproterenol C. Permanent implantable pacemaker D. Benign rhythm no intervention
C. Permanent implantable pacemaker
If initially haemodynamically unstable --> transvenous pacing, until permanent pacemaker can be placed.
Mobitz type 2/2:1 AV block has risk of deteriorating into complete heart block.
111
A thin, tall man 31-year-old had a sudden onset of right-sided chest pain, especially during inspiration. He is breathless, and his blood pressure is 90/60 mmHg on both arms. Which of the following is the most likely diagnosis? A. Acute myocardial Infarction B. Dissecting thoracic aortic aneurysm C. Pneumothorax D. Tietze’s syndrome (costochondritis)
C. Pneumothorax
112
ST depression V4-V6, T inversion, +ve troponin, give aspirin and clopidogrel, in CCU, next step? A. LMWH B. PCI C. Streptokinase
A. LMWH
113
Indication for thrombolysis in acute PE. A. Circulatory collapse B. Contraindicated for heparin C. DVT in leg D. Pulmonary hypertension
A. Circulatory collapse
If high risk: shock or hypotension --> thrombolysis/surgery
Non high risk: start LMWH or UFH
114
Moderate to severe MS on echo with AF, prophylaxis for cardioembolic stroke? A. Aspirin B. Enoxaparin C. Rivaroxaban D. Warfarin
D. Warfarin
115
19/F acute palpitations and chest discomfort, took over the counter nasal decongestants. BP 90/60, HR 200 regular, ECG: narrow complex tachycardia. CXR normal. Cold extremities. Diffuse wheeze. A. DC cardioversion B. IVATP C. IV diuretics D. Inhaled bronchodilator
A. DC cardioversion
116
Which of the following is most suggestive of acute MI? A. LBBB B. RBBB C. Right axis deviation and prolonged PR interval D. Diffuse concave ST elevation and PR depression
A. LBBB
117
22 years old university student was evaluated for an episode of syncope during basketball match. His father died at his early 40s. BP normal. Apex not displaced. Pulse 60 regular. ESM at aortic region. Diagnosis? A. HOCM B. Thyrotoxic CM C. Dilated CM D. Rheumatic aortic stenosis
A. HOCM
