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Flashcards in Cardiovascular Deck (18)
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1

A 65 year old man presents with central crushing chest pain for the first time. He is transferred immediately to the closest cardiac unit to undergo a primary percutaneous coronary intervention. There is thrombosis of the left circumflex artery only. Angioplasty is carried out and a drug-eluding stent is inserted. What are the most likely changes to have occurred on ECG during admission?

A) ST depression in leads V1-4
B) ST elevation in leads V1-6
C) ST depression in leads II, III and aVF
D) ST elevation in leads V5-6
E) ST elevation in leads II, III, aVF

D) ST elevation in leads V5-6

Presented with STEMI - indication for PCI.
NSTEMI indicates ischaemia rather than infarction - PCI within 48h
Angiogram shows left circumflex artery occluded, resulting in lateral infarct. This area is represented by leads V5-6 (D)
V1-4 represents the territory of the LAD artery.
If the entire left mainstream has been occluded, changes would have shown throughout V1-6 (B).
Leads II, III and aVF (C&E) point to an interior infarct and involvement of the RAD artery.

V1-2 - anterior - diagonal branch of LAD
V3-4 - septal - septal branch of LAD
V5-6 - lateral - left circumflex
V1-6 - anterolateral - left main stem
II, III, aVF - inferior - posterior descending

2

A 78 year old woman is admitted with heart failure. The underlying cause is determined to be aortic stenosis. Which sign is most likely to be present?

A) Pleural effusion on CXR
B) Raised JVP
C) Bilateral pedal oedema
D) Bibasal crepitations
E) Atrial fibrillation

D) Bibasal crepitations

AS will first result in left ventricular failure as a result of increased ventricular pressure as the ventricle tried to pump blood across a narrowed valve.
Initially the pressure load will cause a backlog of blood into the lungs, resulting in pulmonary oedema (D) before enough fluid accumulates as pleural effusions visible on CXR (A).
Earlier signs of pulmonary oedema include upper lobe blood diversion and Kerley B lines as fluid infiltrates the interstitium.
If the backlog continues back into the right heart, eventually signs of right heart failure will be evident including raised JVP (B) and bilateral pedal oedema (C).
Atrial fibrillation (E) may coexist with AS, however it is more commonly associated as a result of MS, as the enlarged atrium disrupts the normal electrical pathways.

3

A patient is admitted with pneumonia. A murmur is heard on examination. What finding points to mitral regurgitation?

A) Murmur louder on inspiration
B) Murmur louder with patient in left lateral position
C) Murmur louder over the right 2nd intercostal space midclavicular line
D) Corrigan's sign
E) Narrow pulse pressure

B) Murmur louder with patient in left lateral position

A murmur louder on inspiration (A) points to a right sided valve lesion.
The right intercostal space midclavicular line (C) is the anatomical landmark for the aortic valve. The mitral area is over the apex.
A murmur louder with patient in the left lateral position (B) is associated with mitral lesions. If heard, you should determine whether the murmur radiates to the axilla.
Corrigan's signs (D) (visibly exaggerated pulsing carotids) is one of the many signs of a hyperdynamic circulation associated with AR.
A narrow pulse pressure (E) is a sign of AS

4

A 79 year old woman is admitted to CCU with unstable angina. She is started on appropriate medication to reduce her cardiac risk. She is hypertensive, fasting glucose is normal and cholesterol is 5.2. She is found to be in atrial fibrillation. What is the most appropriate treatment?

A) Aspirin and clopidogrel
B) Digoxin
C) Cardioversion
D) Aspirin alone
E) Warfarin

E) Warfarin

Ideally this patient should be started on antihypertensives, a beta blocker and a statin. There is no indicated for hypoglycaemic at present.
There is no indication that this is acute AF and she does not seem to be compromised in a female of this age, cardioversion (C) is unlikely to be successful.
She should be rate-controlled but the beta blockade is more appropriate in light of there ischaemic heart disease.
Whether to start anticoagulation (A) is a decision that has to be tailer made for each individual patient.
The CHADS2 score is a quick and dirty but very useful way of predicting risk of subsequent stroke as a result of AF and helps guide the prescription of prophylactic anti platelets or anticoagulants.
CHADS2 - 0 = aspirin
1 = warfarin or aspirin
2+ = warfarin

CHA2DS2VASc -
Congestive heart failure (0/1)
Hypretension (0/1)
Age 75+ (0/2)
Diebetes mellitus (0/1)
Previous stroke/TIA/TE (0/2)
Vascular disease (0/1)
Age 65-74 (0/1)
Sex female (0/1)

5

A 55 year old man has just arrived in A&E complaining of 20 minutes of central crushing chest pain. Which feature is most indicative of myocardial infarction at this moment in time?

A) Inverted T waves
B) ST depression
C) ST elevation
D) Q waves
E) Raised troponin

C) ST elevation

ACS determined by presence of 2/3 factors - chest pain, ECG changes and cardiac enzyme rise.
Inverted T waves (A) and ST depression (B) are signs of ischaemia.
ST elevation, Q waves and raised trops are all signs of infarction.
ST elevation (C) is a very good predictor of imminent infarction (positive troponin). However if the patient is treated quickly enough with thrombolysis or PCI, infarction can be avoided.
Q waves take time to develop
Troponin should be tested 12h after the start of the chest pain.

6

A 66 year old woman presents to A&E with a 2 day history of SOB. The patient notes becoming progressively short of breath as well as a sharp pain in the right side of the chest which is most painful when taking a deep breath. The patient also campaigns of mild pain in the right leg, though there is nothing significant on full cardiovascular and respiratory examination. Heart rate is 96 and reap rate is 12. The patient denies any weight loss or long haul flights but mentions undergoing a nasal polypectomy 3 weeks ago. The most likely diagnosis is:

A) Muscular strain
B) Heart failure
C) Pneumothroax
D) Angina
E) Pulmonary embolism

E) Pulmonary embolism

Patients most often complain of SOB, pleuritic chest pain, and haemoptysis. Clinical signs can include a pleural rub, coarse crackles, and atrial fibrillation. In massive PE there can be a raised JVP, RR, HR and low BP.
Muscular pain (A) typically occurs on movement and is not associated with SOB or leg pain and there is usually indicator of injury to a preceding stressor.
Heart failure (B) is unlikely due to acute presentation
Pneumothorax (C) does not have association with leg pain and there is hyper-resonance on chest exam.
Angina (D) is a dull or crushing chest pain in the centre of the chest

Geneva scoring system useful for predicting risk of PE - <3 is mild risk, 4-10 moderate, 11+ is high risk.
>65 years (0/1)
Previous DVT/PE (0/3)
Surgery/fracture <4 weeks (0/2)
Malignancy (0/2)
Unilateral leg pain (0/3)
Unilateral oedema (0/4)
Haemoptysis (0/2)
HR 75-94 (0/3)
HR >95 (0/5)

7

A 59 year old man presents for a well person check. A CVS, Resp, GI and Neuro exam is performed. No significant findings are found, except during auscultation a mid systolic click followed by a late systolic murmur is heard at the apex. The patient denies any symptoms. The most likely diagnosis is:

A) Barlow syndrome
B) Austin Flint syndrome
C) Patent ductus arteriosus
D) Graham Steell murmur
E) Carey Coombs murmur

A) Barlow syndrome

This patient is suffering from a mitral valve prolapse (Barlow syndrome, click murmur syndrome) (A). A mid-systolic click followed by a late systolic murmur is heard at the apex as the thickened mitral valve leaflet is displaced into the left atrium during systole.
An Austin Flint murmur (B) produces a low pitched mid-diastolic rumble at the apex. Classically, mitral valve displacement as well as aortic turbulence due to regurgitation qualifies as an Austin Flint murmur.
A PDA (C) produces a constant machinery murmur.
A Graham Steell murmur (D) is typically heard best at the left sternal edge, second intercostals space during inspiration. A high pitched early diastolic murmur is head associated with pulmonary hypertension.
A Carey Coombs murmur (E) is a short, mid-diastolic rumble heard best at the apex due to turbulent blood flow over a thickened mitral valve, most often due to rheumatic fever.

8

A 58 year old man has made an excellent functional recovery after an anterior MI. He is entirely asymptomatic and there is no abnormality on physical examination. His BP is 134/78 and he is undertaking a cardiac rehabilitation programme. Which of the following would you not recommend as part of his secondary prevention planning?

A) Aspirin
B) Lisinopril
C) Simvastatin
D) Bisoprolol
E) Omega 3 fatty acids

E) Omega 3 fatty acids

There is strong clinical trial evidence for the other four classes of drugs (A-D), although it is not clear how long the duration of therapy should be in each case. This benefit is applicable to normotensive patients with 'normal' LDL levels, although

9

A 25 year old woman with known mitral valve prolapse develops a low grade fever, malaise, and night sweats within a couple of weeks of a major dental procedure. Examination reveals a HR of 110bpm, which is regular. Tender vasculitic lesions on the finger pulps and microscopic haematuria are seen. Which investigation is most likely to provide a definitive diagnosis?

A) FBC
B) ECG
C) Autoantibody screen
D) Blood culture
E) Coronary angiography

D) Blood culture

Subacute bacterial endocarditis - strep viridians
The definitive diagnosis is by blood culture (D) although echo (B) will show vegetations on affected heart valves. Although the lesions described are vasculitic, in this case they are caused by antigen-antibody complexes triggered by infection.

10

An asymptomatic 31 year old woman ha been referred for cardiological assessment. After her ECG she was told that she had mitral valve prolapse and would like further information on this condition. Which of the following statements is correct?

A) Beta blocker therapy is indicated
B) ACE inhibitor therapy is indicated
C) One or both leaflets of the mitral valve are pushed back into the left atrium during systole
D) Significant mitral regurgitation will eventually develop
E) Exercise should be restricted

C) One or both leaflets of the mitral valve are pushed back into the left atrium during systole

There is no indication for ACE inhibitor therapy (B), while beta blocker (A) may be used for management of arrhythmias if these occur.
Mitral regurgitation (D) is unlikely to occur, although it is a possibility.
There is no need to limit exercise (E) in an asymptomatic patient.
There is a risk for endocarditis - ?antibiotic prophylaxis.

11

A 69 year old woman complains of intermittent palpitations, lasting several hours, which then stop spontaneously. She also suffers from asthma. Holter monitoring confirms paroxysmal atrial fibrillation. Which of the following statements is correct regarding the management of this patient?

A) Digoxin effectively prevents recurrence of the arrhythmia
B) Anticoagulation is not necessary
C) Sotalol may be effective
D) Amiodarone should be avoided
E) Flecainide orally may be an effective as-needed treatment to abort an attack

E) Flecainide orally may be an effective as-needed treatment to abort an attack

Oral flecainide is now widely recommend to avoid continuous therapy. Propafenone is used in a similar way.
Digoxin (A) is not effective in this situation ; sotalol (C) may be used but should be avoided because of the patient's asthma.
Amiodarone (D) is effective, but has numerous serious adverse reactions including pulmonary fibrosis, liver damage, peripheral neuropathy, and abnormal thyroid function.
Anticoagulation (B) is very important to prevent strokes, although in low-risk patients aspirin may be adequate. In patient where drug therapy is ineffective or poorly tolerated, ablation therapy can have a high success rate.

12

A 57 year old man is reviewed in a hypertension clinic, where it is found that his BP is 165/105 despite standard doses of amlodipine, perindopril, doxazosin and bendroflumethiazide. Electrolytes and physical examination have been, and remain, normal. Which of the following would be your next stage in his management?

A) Arrange for his medication to be given under direct observation
B) Add spironolactone to his medication
C) Arrange urinary catecholamine assays
D) Request an adrenal CT scan
E) Add verapamil to his medication

A) Arrange for his medication to be given under direct observation

Poor adherence to therapy is probably the most common cause of apparent resistance to hypertensive therapy. In cases where this occurs despite good adherence, spironolactone (B) is often highly effective, although it is not clear why.
Verapamil (E) is very occasionally added to a dihydropyridine in severe hypertension.
If he is already a patient of the hypertension clinic, one can presume that he has been screened for possible secondary causes (C&D), so this is very likely to be primary hypertension.

13

A 44 year old woman presents with episodes of headaches, associated with anxiety, sweating and a slow pulse rate. At the time of her initial consultation, her BP was 150/95 seated but 24h ambulatory monitoring shows a peak of 215/130, associated with the symptoms described above. Which of the following would be your initial diagnostic procedure?

A) MRI abdomen and pelvis
B) Measurement of random plasma catecholamines
C) Measurement of urine metanephrines over several 24h periods
D) Glucose tolerance test
E) Pharmacological provocation using clonidine

C) Measurement of urine metanephrines over several 24h periods

Although there is some debate on this issue, the general consensus is that the best answer is C, which is highly sensitive and specific, with levels as much as ten fold greater than normal.
B may be normal between episodes, and D may well be abnormal but would not be diagnostic, and E is not recommended or necessary. Option A will be essential once the diagnosis is definite or highly probable.

14

A 56 year old man presents to A&E with a 2 hour history of central chest pain radiating to the left arm. He is anxious, nauseated and sweaty. His HR is 120bpm in sinus rhythm and the ECG reveals ST elevation in leads II, III, and aVF. The troponin level is significantly raised. This is certainly acute MI. Which is the most likely coronary vessel to be occluded?

A) Circumflex artery
B) Left anterior descending
C) Right coronary
D) Left main coronary
E) Posterior descending

C) Right coronary

This is the artery that supplies the inferior and posterior aspects of the left ventricle.
Circumflex (A) would affect the anterolateral territory (I, aVL, V5-6)
LAD (B) supplies the septum (V1-4)
Left main (D) includes the circumflex and LAD
Posterior descending (E) affects a limited portion of the posterior wall, and is associated with tall R waves in V1-2.

15

A 45 year old woman complains of increasing SOB on exertion, as well as orthopnoea, for the previous 3-4 months. She had apparently recovered from pericarditis about a year earlier. on ECG there is low voltage, especially in the limb leads, and the CXR shows pericardial calcification. The presumptive is constrictive pericarditis. Which of the following physical signs would be consistent with this?

A) Increased jugular distention on inspiration
B) 3rd heart sound
C) 4th heart sound
D) Rales at both lung bases
E) Loud 1st and 2nd heart sounds

A )Increased jugular distention on inspiration

A is Kussmaul's sign.
3rd and 4th heart sounds (B&C) are associated with heart failure , but not pericardial diseases.
Lung signs are less likely than right sided ones, such as ascites and peripheral oedema (C)
The first and second heart sounds are usually reduced as the pericardial wall is thickened and sound transmission is reduced (E)

16

A 71 year old man is being treated for congestive heart failure with a combination of drugs. He complains of nausea and anorexia, and has been puzzled by observing yellow rings around lights. His pulse rate is 53bpm and irregular and BP is 128/61. Which of the following mediations is likely to be responsible for these symptoms?

A) Lisinopril
B) Spironolactone
C) Digoxin
D) Furosemide
E) Bisoprolol

C) Digoxin

The yellow-tinged vision is particular to digoxin. The slow pulse, with probable ectopics, together with the subjective symptoms, suggests toxicity and plasma digoxin should be measured, with lowering of the dosage or withdrawal of the drug, which is not considered first line therapy in any case in the management of congestive heart failure.

17

A 29 year old woman goes to see her GP complaining of fatigue and palpitations. She says she has lost weight, through without dieting. On examination her HR is 120bpm and irregularly irregular. Her BP is 142/89 and her BMI is 19. There are no added cardiac sounds. The ECG confirms the diagnosis of atrial fibrillation. What would you suggest as the most useful next investigation?

A) TFTs
B) ECG
C) CXR
D) FBC
E) Fasting blood sugar

A) TFTs

This clinical picture strongly suggests thyrotoxicosis. This is probably the most common cause of AF in a young person, particularly in absence of valve disease.
An ECG (B) will be conducted to rule out valve disease.
An FBC (D) and fasting sugar (E) will be carried out routinely, and a CXR (C) may form part of a search for a retrosternal goitre if indicated.

18

A 58 year old man has made an excellent functional recovery after an anterior MI. He is entirely asymptomatic and there is no abnormality on physical examination. His BP is 134/78 and he is undertaking a cardiac rehabilitation programme. Which of the following would you not recommend as part of his secondary prevention planning?

A) Aspirin
B) Lisinopril
C) Simvastatin
D) Bisoprolol
E) Omega 3 fatty acids

E) Omega 3 fatty acids

There is strong clinical trial evidence for the other four classes of drugs (A-D), although it is not clear how long the duration of therapy should be in each case. This benefit is applicable to normotensive patients with 'normal' LDL levels, although what constitutes normal in this case is controversial. Targets are likely to be reduced in the near future.