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1

A 23 year old female who has history of a cardiac condition wants to start a family with her husband and has been referred to the cardiology clinic for advice. What condition is an absolute contra indication to pregnancy?

a) Bicuspid aortic valve
b) ASD
c) PFO
d) Mitral valve prolapse
e) Primary pulmonary hypertension

e) Primary pulmonary hypertension

- Pulmonary hypertension is the only absolute contraindication as it can rapidly deteriorate during pregnancy.
- MVP and bicuspid aortic valve should be monitored. PFO and ASD are not contraindications.

2

A 68 year old asthmatic presents with shortness of breath. She also has a PMH of hypertension for which she is prescribed ramipril. On examination she is found to have a BP of 130/80mmHg, pulse of 90 irregularly, irregular and bilateral wheeze and normal heart sounds. A CXR reveals cardiomegaly.
What is the most appropriate treatment of her AF?

a) Verapamil
b) Flecainide
c) Atenolol
d) Amiodarone
e) Digoxin

e) Digoxin

- Rate control is the most appropriate in this case. Digoxin should be utilised due to the cardiomegaly and history of asthma which means verapamil and atenolol should be avoided due to potential of precipitating heart failure and worsening asthma respectively.

3

A 60 year old male presents with general malaise, pyrexia and night sweats. They have a past history of rheumatic heart disease. On examination there is evidence of a pansystolic murmur. Which is a new clinical finding. What organism is the most likely to have caused these symptoms?

a) Strep. Viridans
b) HACEK group
c) Staph. Aureus
d) Staph Epidermidis
e) MRSA

a) Strep. Viridans

- The most common organism to lead to infective endocarditis on a native valve is Strep Viridans. Staph Aureus and staph epidermidis are most likely to be the causative agents in prosthetic valve endocarditis. HACEK ad MRSA are both more rare causes.

4

A 75 year old presents with shortness of breath on exertion. On further questioning she is unable to lie flat due to breathlessness and has woken up during the night gasping for air. She has a history of hypertension. On examination there is bibasal crackles. The CXR reveals small bilateral pleural effusions, upper lobe diversion and bat wing oedema. What is the most likely diagnosis?

a) Cryptogenic fibrosing alveolitis
b) Pulmonary oedema
c) Interstitial lung disease
d) COPD
e) Pneumonia

b) Pulmonary oedema

- The patient describes orthopnoea and paroxysmal nocturnal dyspnoea which are characteristic of pulmonary oedema. The CXR is also indicative as pulmonary oedema shows bilateral pleural effusion, perihilar shadowing (bat wing oedema), upper lobe diversion and Kerley B lines. The background of hypertension suggests an underlying cause for her cardiac failure.

5

Which of the following suggests the presence of mitral regurgitation as well as mitral stenosis?

a) Displaced apex beat b) Raised JVP
c) Atrial fibrillation
d) Loud P2
e) Localised tapping apex beat

a) Displaced apex beat

- Mitral stenosis on its own does not lead to left ventricular dilatation and does not cause a displaced apex beat. If there is a displaced apex beat this is suggestive of mixed mitral disease. The other options occur in mitral stenosis.

6

A 81 year old male with a history of hypertension and inferior MI is seen in the cardiology clinic due to worsening angina and heart failure and 2 syncopal episodes. He is found to have an ejection systolic murmur loudest at the apex. Which investigation will confirm the most likely diagnosis?

a) Blood cultures
b) Coronary angiography
c) Exercise tolerance test
d) ECG
e) Echocardiography

e) Echocardiography

- Aortic Stenosis explains all of the symptoms of worsening angina and heart failure and the 2 episodes of syncope. Although the murmur is loudest at the apex mitral regurgitation is less likely to explain the syncopal episodes.An Echocardiograph will confirm the diagnosis. Coronary angiography should be performed but is not used for the diagnosis.

7

A 72 year old gentleman has recently had a mitral valve replacement. He is now complaining of fatigue and shortness of breath. On examination he is pale and his sclera appear yellow. Bloods reveal a low haemoglobin, increased bilirubin, increased reticulocyte count and fragmented red cells on blood film. What is the most likely diagnosis?

a) B12 deficiency
b) Cholangitis
c) Iron deficiency anaemia
d) Infective endocarditis
e) Haemolytic anaemia

e) Haemolytic anaemia

- The most likely diagnosis is Haemolytic anaemia due to cardiac haemolysis. The mechanical valve can cause direct trauma to the red cells and thus lead to lysis. Haemolytic anaemia is evidenced by the reduced haemoglobin, increased reticulocyte count, increased LDH, increased unconjugated bilirubin and reduced haptoglobin. Spherocytes and fragmented red cells can appear on blood film.

8

Which of the following is not a feature of hypokalaemia on an ECG?

a) U wave
b) Prolonged QT
c) Flattened t wave
d) Delta wave
e) ST depression

d) Delta wave

9

A 62 year old has had two syncopal episodes. She complains of intermittent palpitations. There is nil of note on examination and her bloods are normal. What is a useful first investigation?

a) Echocardiogram
b) 24 hour ECG
c) EEG
d) Exercise tolerance test
e) Nil required

b) 24 hour ECG

- In a patient with syncopal episodes and a normal clinical examination who is complaining of intermittent palpitations, a 24 hour ECG is a reasonable first investigation. This will exclude any cardiac arrhythmias. In some patients reassurance is appropriate if the patient is young and it is clearly syncopal and no symptoms suggestive of cardiac disease. Aortic stenosis can lead to syncope however normally a murmur would be heard. If there was concern of this an echocardiogram should be organised.

10

A patient presents with chest pain and shortness of breath. She has rheumatoid arthritis. She is tachycardic and hypotensive. She has a raised JVP and an ECG shows low QRS voltages.
What is the most likely diagnosis?

a) Pericarditis
b) Cardiac tamponade
c) Constrictive pericarditis
d) Pulmonary fibrosis
e) Myocarditis

b) Cardiac tamponade

- Pericardial effusions can occur in rheumatoid arthritis and occur more commonly than constrictive pericarditis and acute pericarditis. In this case the effusion has led to tamponade as typified by the clinical findings. It leads to an increased JVP and classically although rarely seen Becks Triad of jugular venous distension, hypotension and diminished heart sounds. Pulsus paradoxus is also a feature. Pericarditis leads to saddled shaped ST elevation. Myocarditis shows variable ECG findings however does not explain all the clinical findings.

11

Which of the following suggests more severe mitral regurgitation?

a) Split S2
b) Loudness of murmur
c) Soft S1
d) Length of murmur
e) Displacement of apex beat and systolic thrill

e) Displacement of apex beat and systolic thrill

- As mitral regurgitation becomes more severe, the left ventricle enlarges and the apex beat displaces and a systolic thrill can develop.

12

A 65 year old gentleman with type 2 diabetes mellitus is found incidentally to have left bundle branch block on his ECG. It had not been present on previous ECGs. An ECHO reveals no structural abnormality. You want to exclude a myocardial infarct.
What investigation should be performed in the first instance?

a) Thalium perfusion scan
b) Exercise tolerance test
c) Coronary angiography
d) CT angiography
e) Repeat ECG

b) Exercise tolerance test

- An ETT should be performed in the first instance to investigate if there is any evidence of ischaemia. This should be performed before any more invasive tests such as angiography. A thallium perfusion scan can be utilised if the patient cannot manage an ETT.

13

An echocardiogram is performed on a patient prior to surgery and reveals a very small pericardial effusion but no other abnormalities. He is asymptomatic. What should be done regarding this prior to surgery?

a) NSAIDs
b) Proceed with surgery, nil required
c) Pericardial drain
d) Postpone surgery and perform further investigations
e) Troponin

d) Postpone surgery and perform further investigations

14

A 68 year old man visits his GP due to palpitations. He had had an MI in the past and LVF and is currently on losartan and furosemide. His pulse is irregularly irregular with a rate of 90, BP 102/70mmHg, normal heart sounds but bibasal crepitations. He is referred to cardiology and an ECHO reveals dilated LA and LV. Which drug should be utilised to control his AF?

a) Digoxin
b) Sotalol
c) Amiodarone
d) Flecainide
e) Diltiazem

a) Digoxin

- Digoxin is the most appropriate as it is useful in symptom control of cardiac failure. Chemical cardioversion is unlikely to be successful due to enlarged LA and LV. Flecainide again is for chemical cardioversion and should be avoided in structural heart disease and sotalol and diltiazem are negative intotropes and may worsen the cardiac failure.

15

A 35 year old gentleman has collapsed twice in the last month. He has a brother and uncle who died in their 20s of sudden cardiac death. An ECHO reveals features of HCOM and a 24 hour ECH shows several short runs of non sustained VT. How do you manage the non sustained VT?

a) Flecainide 100mg
b) Implantable cardiovertor defibrillator
c) Amiodarone 200mg
d) Atenolol 100mg
e) None required

b) Implantable cardiovertor

- Due to evidence of the non sustained VT he is at increased risk of sudden cardiac death and therefore an ICD is appropriate. Amiodarone was previously utilised for medical management but ICDs are now becoming management of choice.

16

A 23 year old present with palpitations intermittently. She is known to suffer from anxiety attacks. However on auscultation of the heart there is evidence of a late systolic murmur with a mid systolic click. It is worsened by the standing position.
What is the most likely diagnosis?

a) Aortic stenosis
b) Mitral stenosis
c) Mitral valve prolapse
d) Normal variant
e) Atrial Myxoma

c) Mitral valve prolapse

- The late systolic murmur with mid systolic click is indicative of mitral valve prolapse where the posterior leaflets bulge during systole. It has been associated with Ehlers Danlos syndrome and Marfans syndrome amongst others. It can very rarely lead to problems such as embolic events. Mitral stenosis causes a diastolic murmur and may be associated with other features such as haemoptysis. AS leads to an ejection systolic murmur. An atrial myxoma is a cardiac tumour and may lead to a mid diastolic murmur and tumour plop.

17

A 70 year old female has had several syncopal episodes. On auscultation there is an ejection systolic murmur radiating to the carotids.
What is the most likely diagnosis?

a) Simple vasovagal episodes
b) Arrthymia
c) Aortic stenosis
d) Mitral regurgitation
e) Hypertrophic cardiomyopathy

c) Aortic stenosis

- Aortic stenosis leads to an ejection systolic murmur radiating to the carotids. It can lead to anginal symptoms and syncopal episodes as in this case and heart failure. There has been some association with haemorrhagic telangiectasia and GI bleeding. MR leads to a pansystolic murmur radiating to the axillae. An arrhythmia may be occurring but given the presence of a murmur aortic stenosis is more likely.

18

A 45 year old male presents with palpitations. He had been drinking heavily the night before. His heart rate is about 140 bpm and is irregularly irregular. What is the most likely diagnosis?

a) Atrial flutter
b) Supraventricular tachycardia
c) Torsades de pointes
d) Paroxysmal atrial fibrillation
e) Ventricular tachycardia

d) Paroxysmal atrial fibrillation

- Given the history of alcohol excess and irregularly irregular pulse this is highly indicative of atrial fibrillation which commonly can occur after alcohol or caffeine excess.

19

In a patient with chest pain with some t wave flattening, which investigation will confirm an NSTEMI?

a) LDH
b) Troponin I
c) AST
d) CK-MB
e) Inflammatory markers

b) Troponin I

- Troponin I and troponin T are specific for myocardial infarction and are elevated within 6-12 hours. AST and LDH are elevated following an MI however these are not specific. CK-MB was previously utilised however troponin is more sensitive and specific.

20

A 65 year old gentleman attends the pre operative clinic. He is awaiting a knee replacement as he has severe osteoarthritis of his knee and hip. He has had a previous myocardial infarction and over the last few months has complained of what sounds like angina pain. Which of the following is useful initially in determining if there is evidence of myocardial ischaemia?

a) Echocardiogram
b) Exercise tolerance test
c) Myocardial perfusion scan
d) Coronary angiography
e) ECG

c) Myocardial perfusion scan

- An exercise tolerance test is normally utilised to assess if there is any evidence of myocardial ischaemia. However in those who are unable to exercise a myocardial perfusion scan can be utilised as an alternative as in this man's case. This is is a non invasive test and if there is any evidence of ischaemia then obviously a coronary angiography would be required before surgery could proceed. An Echo is not useful in showing evidence of ischaemia.

21

A 50 year old female presents with shortness of breath, fatigue and peripheral oedema. On examination she has a raised JVP, pitting oedema, hepatomegaly and ascites. An echo is organised and reveals globally thickened walls oncluding the interatrial septa with atrial dilatation but the ventricles are not dilated. There is an increased scintillation pattern (granular speckling). There is a normal ejection fraction. An ECG shows low voltage complexes. Given the most likely diagnosis, how else might it present?

a) Embolic symptoms
b) Cardiac tamponade
c) Myocardial infarction
d) Liver failure
e) Renal failure

a) Embolic symptoms

- The most likely diagnosis is restrictive cardiomyopathy given the clinical features and echo findings. The clinical findings are similar to those of contrictive pericarditis however the echo in this condition would reveal thickened calcified pericardium and normal wall thickness. Due to the atrial dilatation thrombus formation can occur and patients may present with embolic symptoms.

22

A 65 year old woman during prep assessment is found to have a small pericardial effusion. She is asymptomatic. The rest of her examination, ECG and other investigations are normal.
How do you manage this patient?

a) Pericardiocentesis
b) NSAIDs
c) Coronary Angiography
d) Reassure
e) Furosemide

d) Reassure

- This patient can be reassured as there is no need for pericardiocentenis as the patient is asymptomatic and is haemodynamically stable.

23

A 52 year old gentleman is 5 days post STEMI when he starts to develop chest pain. It is pleurtic in nature and worse on lying down. He is pyrexial and generally unwell. On examination he is tachycardic and there is evidence of a pericardial friction rub. On ECG there is widespread ST elevation.
What is the most likely diagnosis?

a) Dresslers syndrome
b) Cardiac tamponade
c) STEMI
d) Pulmonary embolism
e) Pneumonia

a) Dresslers syndrome

- This patient presents with symptoms and signs of Dresslers syndrome. It is thought to be an immunological reaction which leads to pericarditis and presetns normally 2 to 5 days following MI but can present up to 3 months. As well as chest pain the patient is often suffering from malaise and pyrexia. There may a leucocytosis , eosinophilia and raised ESR. AS with any other causes of pericarditis pericardial; friction rub and widespread ST elevation may be evident.

24

A 50 year old female presents with shortness of breath, fatigue and peripheral oedema. On examination she has a raised JVP, pitting oedema, hepatomegaly and ascites. An echo is organised and reveals globally thickened walls including the interatrial septa with atrial dilatation but the ventricles were not dilated. There is an increased scintillation pattern (granular speckling). There is a normal ejection fraction. An ECG shows low voltage complexes. What is the most likely diagnosis?

a) Constrictive pericarditis
b) Restrictive cardiomyopathy
c) Arrhythmogenic right ventricular cardiomyopathy
d) Dilated cardiomyopathy
e) Hypertrophic cardiomyopathy

b) Restrictive cardiomyopathy

- The most likely diagnosis is restrictive cardiomyopathy given the clinical features and echo findings. The clinical findings are similar to those of constrictive pericarditis however the echo in this condition would reveal thickened calcified pericardium and normal wall thickness. Due to the atrial dilatation thrombus formation can occur and patients may present with embolic symptoms. The other options may be excluded from the echocardiogram findings. In HOCM patients tend no to present with features of right heart failure and on arrhythmogenic right ventricular cardiomyopathy would present with a ventricular arrhythmia. Amyloidosis is the most common cause of restrictive cardiomyopathy and the interatrial septal hypertrophy and granular speckling are suggestive of this as the underlying cause however are not specific and may be seen in other causes. Other causes include sacoidosis and Loefflers endocarditis.

25

A 50 year old female parents with shortness of breath, fatigue and peripheral oedema. On examination she has a raised JVP, pitting oedema, hepatomegaly and ascites. An echo is organised and reveals globally thickened walls oncluding the interatrial septa with atrial dilatation but the ventricles are not dilated. There is an increased scintillation pattern (granular speckling). There is a normal ejection fraction. An ECG shows low voltage complexes. Given the most likely diagnosis
Which drug should she be advised to avoid?

a) Ramipril
b) Digoxin
c) Forosemide
d) Bendroflumethiazide
e) Amiodarone

b) Digoxin

- The most likely diagnosis is restrictive cardiomyopathy given the clinical features and echo findings. The clinical findings are similar to those of constrictive pericarditis however the echo in this condition would reveal thickened calcified pericardium and normal wall thickness. Due to the atrial dilatation thrombus formation can occur and patients may present with embolic symptoms. Patients with restrictive cardiomyopathy most likely secondary to amyloidosis should avoid digoxin as it is thought that digoxin may bind to amyloid fibrils and lead to increased toxicity. There I some suggestion that calcium channel blockers and beta blockers should also be avoided.

26

A 52 year old gentleman is 5 days post STEMI when he starts to develop chest pain. It is pleuritic in nature and worse on lying down. He is pyrexial and generally unwell. On examination he is tachycardic and there is evidence of a pericardial friction rub. On ECG there is widespread ST elevation. Given the most likely diagnosis, what management should be initiated?

a) NSAIDs
b) Thrombolysis
c) IV heparin
d) PCI
e) IV antibiotics

a) NSAIDs

- This patient presents with symptoms and signs of Dresslers syndrome. It is thought to be an immunological reaction which leads to pericarditis and presents normally 2 to 5 days following MI but can present up to 3 months. As well as chest pain the patient is often suffering from malaise and pyrexia. There may a leucocytosis , eosinophilia and raised ESR. AS with any other causes of pericarditis pericardial; friction rub and widespread ST elevation may be evident. NSAIDs are useful in the management and corticosteroids have been used in patients with severe symptoms.

27

A 70 year old female has had several syncopal episodes. On auscultation there is an ejection systolic murmur radiating to the carotids. What is the most likely diagnosis?

a) Simple vasovagal episodes
b) Aortic stenosis
c) Mitral regurgitation
d) Arrhythmia
e) Hypertrophic cardiomyopathy

b) Aortic stenosis

- Aortic stenosis leads to an ejection systolic murmur radiating to the carotids. It can lead to anginal symptoms and syncopal episodes as in this case and heart failure. There has been some association with haemorrhagic telangiectasia and GI bleeding. MR leads to a pansystolic murmur radiating to the axillae. An arrhythmia may be occurring but given the presence of a murmur aortic stenosis is more likely.

28

A 66 year old male with a history of AF on aspirin and bisoprolol presents with symptoms of TIAs. An ECHO and a CT Head do not reveal any abnormalities. How would you manage this patient?

a) Warfarin
b) Carotid endarterectomy
c) Digoxin
d)Clopidogrel
e) Nil

a) Warfarin

- This patient is developing TIAs. On a background of AF this may be due to embolus and thus if there is no major contraindications then the patient should be fully anti-coagulated with warfarin. Previous recommendations say unless contraindicated patients with a history of previous stroke/TIA/thromboembolic event, those over 75 with hypertension, diabetes or vascular disease or those with evidence of valve disease or LVSD should be warfarinised although some suggest now it should be considered in all patients. Endarterectomy is utilised in those with significant carotid artery stenosis. Clopidogrel is not indicated in this case.

29

A patient has just suffered a STEMI and is now found to be in complete heart block. What vessel is likely to have been involved?

a) Right coronary artery
b) Left coronary
c) Left anterior descending artery
d) Left circumflex artery
e) Left marginal artery

a) Right coronary artery

- Conduction defects most commonly complicate inferior STEMIs. The inferior portion of the heart in the majority of people is supplied by the right coronary artery.

30

A 42 year old gentleman with Type 2 Diabetes Mellitus, hypertension and 20 a day smoker, attended A+E with severe crushing central chest pain, sweaty and nausea. His current medication is lisinopril, amlodipine and bendroflumethiazide. He looks diaphoretic, pale and anxious. There is nil else of note on examination. An ECG reveals ST Elevation in II, III and aVF. What is the next most appropriate step?

a) Aspirin, clopidogrel + LMWH
b) Await 12 hour troponin and ECG
c) Primary Percutaneous coronary intervention
d) Thrombolysis
e) Abcicimab

c) Primary percutaneous coronary intervention

- The evidence base shows that patients with acute STEMI should be referred for primary PCI as it is superior to thrombolysis. PCI should be considered first line management and if patients can reach a primary PCI centre within 90 minutes. Protocols vary in regions however often aspirin, clopidogrel and a bolus of heparin is given before PCI

31

A 35 year old female with rheumatoid arthritis presents with pain and tightness behind of the left leg. On examination there is evidence of a swelling in the popliteal fossa of the left knee. What investigation should be organised?

a)D dimers
b) MRI of knee
c) Ultrasound of popliteal fossa
d) Arthroscopy
e) Routine bloods

c) Ultrasound of popliteal fossa

- The most likely diagnosis is a Baker's cyst and an ultrasound should be performed to confirm this. A d-dimer should only be measured if you suspect a DVT and according to the appropriate Well's score.

Wells score is used to indicate DVT and pulmonary embolism.

32

A 40 year old male presents with painful fingers. On examination there is evidence of dactylitis and he is tender over his DIPs and pitting of his nails. His rheumatoid factor is negative. What is the most likely diagnosis?

a) Osteoarthritis
b) Pseudogout
c) SLE
d) Psoriatic arthritis
e) Rheumatoid arthritis

d) Psoriatic arthritis

33

A 81 year old male with a history of hypertension and inferior MI is seen in the cardiology clinic due to worsening angina and heart failure and 2 syncopal episodes. He is found to have an ejection systolic murmur loudest at the apex and on listening to his chest he has findings in keeping with heart failure. His bloods are unremarkable. Which of the following is the most likely to be causing his syncopal episodes and worsening angina and heart failure?

a) Aortic stenosis
b) Mitral regurgitation
c) Coronary artery disease
d) Renal failure
e) Atrial fibrillation

a) Aortic stenosis

- Aortic Stenosis explains all of the symptoms of worsening angina and heart failure and the 2 episodes of syncope. Although the murmur is loudest at the apex mitral regurgitation is less likely to explain the syncopal episodes. In the elderly sometimes the Aortic Stenosis can be heard best at the apex. This gentleman due to his symptomology requires an Echocardiograph and a Coronary Angiography.

34

You are asked to review a 52 year old gentleman who has become suddenly unwell and hypotensive. He had an STEMI 2 days previously. On examination he has a pansystolic murmur lowest at the lower left sternal border and a raised JVP. Further investigation reveals a high right atrial pressure and low left atrial pressure. What is the most likely diagnosis?

a) Aortic regurgitation
b) VSD
c) Tricuspid regurgitation
d) Mitral regurgitation
e) Aortic stenosis

c) Tricuspid regurgitation

- The history and findings of high right atrial pressure suggests tricuspid regurgitation which can occur post MI and is more commonly seen in those with chronic lung disease, endocarditis, rheumatic heart disease and congenital abnormalities. It leads to a pansystolic murmur at the LLSE, raised JVP and pulsatile liver and sometimes a RV impulse.

35

A 58 year old gentleman has severe central crushing chest pain for about half an hour which is finally relieved by GTN. There is evidence of ST depression in the anterolateral leads and his troponin is elevated. He is treated with aspirin, clopidogrel and LMWH. What is the next appropriate management?

a) Exercise tolerance test
b) Urgent coronary angiography as an inpatient
c) Cardiac rehabilitation
d) Coronary angiography as an outpatient
e) Discharged with outpatient cardiac clinic up

b) Urgent coronary angiography as an inpatient

- This patient has had an NSTEMI and thus he need coronary angiography urgently as an inpatient as he is at high risk.

36

A 65 year old male with type 2 diabetes mellitus presents with severe crushing central chest pain associated with autonomic features. This lasted for one hour before it was relieved by GTN spray. An ECG shows anterolateral ST depression and his troponin is elevated, He develops further chest pain at rest despite being commenced on aspirin, clopidogrel, atenolol and LMWH. An urgent coronary angiography is planned. What other management should be initiated?

a) Abciximab
b) Streptokinase
c) None required
d) IV heparin
e) Tenecteplase

a) Abciximab

- This patient is at high risk of developing a STEMI due to presenting with an NSTEMI and despite optimal medical management continuing to have pain. He is also a diabetic. It would therefore be appropriate to commence abciximab a GP IIb/IIIa inhibitor as it has been shown to improve survival in those who are at high risk and coronary intervention is planned.

- Abciximab is a type of "blood thinner" used to prevent blood clots during certain procedures used to open up the blood vessels in the heart (e.g., balloon angioplasty, coronary stent placement, percutaneous coronary intervention-PCI).

37

Which of the following is a risk factor for the development of Torsades de pointes?

a) Hyperkalaemia
b) Hyponatraemia
c) Hypothermia
d) Hypercalcaemia
e) Hypermagnesaemia

c) Hypothermia

- Hypothermia can lead to a prolonged QT interval and thus Torsades de pointes is at risk of developing.
The other options are not causes of prolonged QT.

38

A 72 year old gentleman with a history of ischaemic heart disease, has been unwell with diarrhoea and vomiting. He complains of intermittent palpitations and dizziness. He is brought to hospital and starts to complain of an episode and is found to have a broad complex tachycardia with the QRS complexes appearing to twist around the baseline. His blood pressure is 140/90 and GCS is 15. How would you manage this patient?

a) Atropine
b) Amiodarone
c) Adrenaline
d) IV magnesium
e) Adenosine

d) IV magnesium

- The most likely diagnosis is Torsades de Pointes. This polymorphic ventricular tachycardia occurs when there is a prolonged QT interval which leads to the QRS complexes amplitudes varying. Prolonged QT syndrome can be secondary to congenital long QT syndrome such as Jervell and Lange Nielsen or can be secondary to MI, certain drugs such as erythromycin, tricyclic antidepressants and antipsychotic or metabolic abnormalities such as hypocalcaemia, hypomagnesaemia or hypokalaemia (secondary to diarrhoea and vomiting in this case). The treatment of choice in stable patients (as in this case) is IV magnesium. Obviously if a patient is unstable then DC Cardioversion is required.

39

A 24 year old female is 22 weeks pregnant. She attends an antenatal clinic appointment. She has been very well throughout her pregnancy and has no past medical history. On examination there is no evidence of oedema. Her blood pressure is 110/70 mmHg and her heart rate is 88 bpm. Auscultation reveals an ejection systolic murmur over the aortic area which radiates to the carotids and varies on posture changes. This was not evident at her previous visit and she is not complaining of chest pain, palpitations or shortness of breath. Her chest is clear.

a) Bicuspid aortic valve
b) Infective Endocarditis
c) Aortic Stenosis
d) Innocent murmur
e) Mitral regurgitation

d) Innocent murmur

- The most likely diagnosis is an innocent murmur. The patient is pregnant and therefore this is most likely a flow murmur. These are typically crescendo decresendo systolic murmurs radiating to the carotids but the patient is otherwise well and there is no history. Innocent flow murmurs are systolic and can also occur in children. Aortic stenosis is unlikely given the age of the patient and the lack of previous history.

40

Which of the following is associated with the worst prognosis in those with aortic stenosis?

a) Left ventricular hypertrophy
b) Left ventricular failure
c) Moderate aortic valve calcification
d) Asymptomatic disease
e) Mild aortic regurgitation

b) Left ventricular failure

- Poor prognosis in those with Aortic stenosis includes moderate to severe calcification, co-existent severe aortic regurgitation and LVF.
- The worst prognosis from these options is LVF.

41

A temporary single chamber pacing wire is being inserted for a patient with complete heart block. Where should the lead be positioned?

a) Right atrium
b) Right ventricle apex
c) Left ventricular apex
d) Left atrium
e) Bundle of His

b) Right ventricle apex

42

A 70 year old gentleman has heart failure which is thought to be secondary to hypertension. His current medication is 40mg BD of furosemide, 4mg of perindopril and 100mg of spironolactone. He has recently attended A and E with an angina attack. He is referred to the cardiology clinic as he is having syncopal episodes. You review him at the clinic and He is found to be hypertensive at 175/105mmHg and have a heart rate of 101. There is evidence of bibasal crepitations and a systolic murmur loudest over the aortic area. A CXR was organised and revealed cardiomegaly and pulmonary oedema. You confirmed your suspicion of Aortic Stenosis by ordering an Echocardiography. Out of the following what is the the likely cause of this?

a) Degenerative aortic stenosis
b) Rheumatic fever
c) Infective endocarditis
d) Bicuspid aortic valve
e) Congenital valve deformity

a) Degenerative aortic stenosis

- This is the most common cause. Calcification of the valve occurs due to senile degeneration of the valve. High Cholesterol and diabetes contribute. The other causes you would expect to occur at an earlier age except infective endocarditis which can occur at any age.

43

A 74 year old man has a history of hypertension. He presents to A and E with a sudden onset of palpitations.He is tachycardic with at a rate of 140. An ECG was performed and revealed a narrow complex tachycardia with a rate of around 150 and a saw tooth pattern. The ECG showed which of the following rhythms?

a) Atrioventricular re entrant tachycardia
b) Ventricular tachycardia
c) Atrial fibrillation
d) AV nodal re entrant tachycardia
e) Atrial flutter

e) Atrial flutter

- Atrial Flutter is the second most common tachycardia following atrial fibrillation. In this example the saw tooth pattern is classical and is often observed most clearly in leads II, III and aVF. There can be variable degrees of block in this example there is 2:1 block. Like any other tachyarrhythmias urgent DC cardioversion is required if the patient is compromised i.e. BP less than 100/60mmHg, evidence of heart failure or chest pain. Chemical cardioversion can be achieved with amiodarone. Rate control may be decided to be the most appropriate option and the drugs normally utilised for this purpose are a betablocker such as bisoprolol or calcium channel blockers such as verapamil.

44

A 72 year old man has had several episodes of collapse and TIAs. He had suffered from an extensive Myocardial Infarction previously. The only finding on clinical examination is a displaced apex beat. An ECG revealed anterior ST elevation although he is currently pain free. What further investigation is the most appropriate for diagnosis of the underlying diagnosis?

a) CT scan
b) Echocardiogram
c) Transoesophageal echocardiogram
d) Cardiac MRI
e) Coronary angiography

d) Cardiac MRI

- A left ventricular aneurysm is a likely possibility due to the persistence of the ST elevation with no chest pain and history of previous MI. The aneurysm would provide an environment for a thrombus to form and lead to an embolic source causing TIAs. The preferred initial imaging is a cardiac MRI.

45

A 29 year old male presents with a history of intermittent palpitations. He is normally fit and well. He is a non smoker and takes little alcohol. These episodes can last for a few minutes to an hour. He is aware of his heart racing, it feels regular but very fast and he feels dizzy and short of breath. He has not noticed any triggering factors. There is no family history of any heart disease. Examination is normal Which of the following is the most likely diagnosis?

a) Paroxysmal ventricular fibrillation
b) Paroxysmal atrial fibrillation
c) Torsades de Pointes
d) Supraventricular Ectopics
e) Paroxysmal supraventricular tachycardia

e) Paroxysmal supraventricular tachycardia

- The history of a regular fast tachycardia with no history or structural heart disease makes the most likely diagnosis an SVT. It can occur in young people although the risk does increase with age. The risk of developing SVT also increases with previous myocardial infarction, MVP, pericarditis, alcoholism and chronic lung disease. If the palpitations were irregular then PAF would be suspected. Usually ectopics are described by patients as their hearts skipping a beat.

46

A 65 year old gentleman with previous valvular heart surgery presents with dyspnoea, ankle oedema and fatigue. On examination there is evidence of a raised JVP worsened by inspiration and has rapid x and y descents. There is also evidence of a pericardial knock and pulsatile hepatomegaly. What is the most likely diagnosis?

a) Constrictive pericarditis
b) Dilated cardiomyopathy
c) Pericardial effusion
d) Restrictive cardiomyopathy
e) Hypertrophic obstructive cardiomyopathy

a) Constrictive pericarditis

- The most likely diagnosis is constrictive pericarditis. There is evidence of Kussmauls sign and prominent X and y descents which is indicative of this although is not specific and may be observed in restrictive cardiomyopathy which can present sin a similar fashion. However the pericardial knock sudden cessation of ventricular filling in early diastole) and previous history of cardiac surgery makes constrictive pericarditis more likely. The echo can be used to differentiate between them. Pericardial effusion present more acutely.

47

A 42 year old gentleman with Type 2 Diabetes Mellitus, hypertension and 20 a day smoker, attended A and E with severe crushing central chest pain, sweaty and nausea. His current medication is lisinopril, amlodipine and bendroflumethiazide. He looks diaphoretic, pale and anxious. There is nil else of note on examination. An ECG reveals ST Elevation in II, III and aVF. What is the next most appropriate step?

a) Primary percutaneous coronary intervention
b) Thrombolysis
c) Aspirin, clopidogrel and LMWH
d) Await 12 hour troponin and ECG
e) Abciximab

a) Primary cutaneous coronary intervention

- The evidence base shows that patients with acute STEMI should be referred for primary PCI as it is superior to thrombolysis. PCI should be considered first line management and if patients can reach a primary PCI centre within 90 minutes. Protocols vary in regions however often aspirin, clopidogrel and a bolus of heparin is given before PCI

48

A 69 year old gentleman was being treated for a chest infection with antibiotics. He has previous history of myocardial infarction and as well as the current antibiotic course he is also taking aspirin, atorvastatin and perindopril. He then collapses 2 days after the antibiotics began and was taken to A and E. When you examine him he has a BP of 130/80mmHg, heart rate of 80 bpm and he rest of his exam is unremarkable. You notice however on the cardiac monitor he is having short runs of torsade de points. What is the most likely antibiotic that he has been prescribed?

a) Co amoxiclav
b) Clarithromycin
c) Doxycycline
d) Cephalexin
e) Amoxicillin

b) Clarithromycin

- Torsades de Points is a ventricular tachycardia which is polymorphic and occurs with QT prolongation. Macrolides e.g. erythromycin, clarithromycin and quinolones lead to prolongation of QT interval. Erythromycin should be avoided with simvastatin due increased risk of rhabdomyolysis.

49

A 23 year old female who has history of a cardiac condition wants to start a family with her husband and has been referred to the cardiology clinic for advice. What condition is an absolute contra indication pregnancy?

a) Mitral valve prolapse
b) PFO
c) ASD
d) Primary pulmonary hypertension
e) Bicuspid aortic valve

d) Primary pulmonary hypertension

- Pulmonary hypertension is the only absolute contraindication as it can rapidly deteriorate during pregnancy. MVP and bicuspid aortic valve should be monitored. PFO and ASD are not contraindications.

50

A 68 year old asthmatic presents with shortness of breath. She also has a PMH of hypertension for which she is prescribed ramipril. On examination she is found to have a BP of 130/80mmHg, pulse of 90 irregularly, irregular and bilateral wheeze and normal heart sounds. A CXR reveals cardiomegaly. What is the most appropriate treatment of her AF?

a) Flecainaide
b) Amiodarone
c) Digoxin
d) Atenolol
e) Verapamil

c) Digoxin

- Rate control is the most appropriate in this case. Digoxin should be utilised due to the cardiomegaly and history of asthma which means verapamil and atenolol should be avoided due to potential of precipitating heart failure and worsening asthma respectively.

51

A 40 year gentleman is concerned as his brother died whilst playing football following a sudden cardiac arrest. It was discovered that he had Hypertrophic Obstructive Cardiomyopathy on post mortem. How would you screen this gentleman?

a) Dobutamine stress echo
b) ECG at rest
c) Trans oesophageal ECHO
d) Cardiac MRI
e) Exercise

We will never know

52

A 23 year old female has been referred to the cardiology clinic. She has been increasingly short of breath and can barely climb stairs without becoming short of breath. She is found to be hypertensive. An ECHO revealed right atrial hypertrophy and raised right atrial pressure. Cardiac catheterisation was performed and revealed a higher than normal oxygen saturation in the right atrium and ventricle. What is the most likely diagnosis?

a) Atrial septal defect (ostium primum)
b) Pulmonary hypertension
c) Ventricular septal defect
d) Atrial septal defect (ostium secundum)
e) Patent ductus arteriosus

d) Atrial septal defect (Ostium secundum)

- The evidence of higher than normal saturation in the right ventricle evidences a left to right shunt as the saturation is higher in the right ventricle due to it receiving oxygenated blood from the left side of the heart. This means there is an ASD and due to the lack of cyanosis then secundum is the likely defect.

53

In a patient with chest pain, which of the following in the history or clinical examination is most useful in the diagnosis of dissecting aortic aneurysm?

a) Smoking
b) Hypertension
c) Upgoing plantars and lower limb weakness
d) History of sudden severe tearing chest pain radiating to the back
e) Pericardial rub

d) History of sudden severe tearing chest pain radiating to the back

- The history is diagnostic. Neurological signs may be old and from another cause. Pericardial rub is not diagnostic and is seen more often in other causes of chest pain such as pericarditis. A history of hypertension is highly likely however is obviously not diagnostic nor is smoking.

54

A 62 year old woman undergoes thrombolysis for a myocardial infarction. After 48 hours you are asked to review her as she is complaining of shortness of breath and her saturations have dropped to 92 per cent. Her blood pressure is 100/65 mmHg and is tachycardic 110 bpm. On auscultation she has a systolic murmur, loudest at the apex, and bilateral crackles to mid zone. What is the likely cause for her deterioration?

a) Dresslers syndrome
b) LV wall rupture
c) Acute VSD
d) Left ventricular aneurysm
e) Papillary muscle rupture leading to mitral regurgitation

e) Papillary muscle rupture leading to mitral regurgitation

- The most likely cause of this deterioration is rupture of the papillary muscle leading to mitral regurgitation. The posteromedial papillary muscle more likely to rupture due to its vascular supply only by the RCA whereas the anterolateral has supply from LAD an left circumflex. Dresslers Syndrome does not occur until approximately 2 weeks post MI. VSD has a pan systolic murmur and is loudest at the lower left sternal edge.

55

A 60 year old woman has a history of PAF for which she is on warfarin and amiodarone, hypercholesterolaemia for which she takes simvastatin and hypertension on bendroflumethiazide and ramipril. She is suffering from recurrent UTIs and has been advised to drink cranberry juice. What is cranberry juice likely to interact with?

a) Ramipril
b) Simvastatin
c) Bendroflumethiazide
d) Warfarin
e) Amiodarone

d) Warfarin

- Cranberry juice can cause inhibition of cytochrome P450 and thus should avoided with warfarin.

56

A 40 year old man is referred to the cardiology clinic due to increased SOB and several TIAs with left sided weakness and slurred speech. He has no significant PMH, is a non smoker and drinks 10 units of alcohol per week. On examination blood pressure is 145/98 and his pulse was 80 and regular. Although his chest clear there is evidence of a diastolic murmur with postural changes. Bloods are normal. What is the likely diagnosis?

a) Left atrial myxoma
b) Aortic regurgitation
c) Aortic stenosis
d) Mitral stenosis
e) Mitral valve prolapse

a) Left atrial myxoma

- Atrial Myxoma, a gelatinous tumour, most commonly occurring in the left atrium, is the likely diagnosis due to the clinical findings, although a tumour plop can sometimes be heard, and the history of a TIA suggesting embolus from the myxoma. There is no suggestion of AF with thus MS with enlarged Left atrium (leading to potential thrombus and thus embolic source) is not likely.

57

An 18 year old female is referred to the cardiology clinic with shortness of breath on exertion, occasional chest pain on exertion and legs feeling weak. She is short, has a webbed neck and does not look sexually mature. She is hypertensive with a BP of 160/90 mmHg and a HR of 85, regular. What cardiac condition is she most likely to have from the following?

a) Pulmonary stenosis
b) Aortic regurgitation
c) Tetralogy of Fallot
d) Pulmonary hypertension
e) Coarctation of the aorta

e) Coarctation of the aorta

58

In pregnancy, which antiarrhythmic should be utilised as prophylaxis for paroxysmal SVT (supraventricular tachycardia)?

a) Metoprolol
b) Amiodarone
c) Adenosine
d) Flecainide
e) Verapamil

a) Metoprolol

- Metoprolol is thought to be the most appropriate management for SVT in pregnancy

59

A 70 year old woman has had 34 syncopal episodes in the last 4 months. She has recently been prescribed enalapril for hypertension. On examination her blood pressure is 165/120 mmHg, she has aloud ejection systolic murmur and heaving apex beat and bibasal crackles. Which investigation will provide the diagnosis?

a) ECG
b) CXR
c) Echocardiogram
d) Cardiac catheterisation
e) ETT

d) Cardiac catheterisation

- The most likely diagnosis is AS with the history and clinical findings. AS will provide the diagnosis and estimate of the gradient across the valve however catheterisation is the definitive allowing co existent coronary disease to be assessed and more accurate valve gradient.

60

A 15 year old is brought to A and E following a collapse with palpitations. She has significant FH of sudden death including her mother. She has no PMH but has recently been prescribed antibiotics. She has a penicillin allergy. On examination there is nil remarkable. AN ECG is performed and shows a QT interval of 540ms. What is the likely diagnosis associated with her collapse?

a) Lange Nielsen
b) Wolf Parkinson White
c) Lown Ganong Levine syndrome
d) Congenital long QT syndrome
e) Coarctation of aorta

d) Congenital long QT syndrome

- There is evidence of prolonged QT and a family history and thus Congenital QT syndrome is likely. The recent antibiotic prescription may have been erythromycin and thus precipitated the prolonged QT. Torsades de pointes is the arrhythmia leading to sudden death. Lange Nielsen syndrome is another syndrome associated with QT prolongation however is associated with congenital deafness. The Lown Ganong Levine syndrome and WPW are pre excitation syndrome.

61

What are the indications for thrombolysis in a patient presenting with chest pain?

a) 1 mm ST elevation in 2 limb leads
b) 1 mm ST elevation in 2 limb leads
c) 2 mm ST depression in all chest leads
d) T wave inversion in chest leads
e) Q waves in any two leads

a) 1mm ST eleveation in 2 limb leads

- Thrombolysis is indicated if there is ST elevation of 1 mm in two or more limb leads, or 2 mm elevation in 2 adjacent chest leads.

62

A 20 year old has been admitted with chest pain. He admitted to using cocaine and is found to have a STEMI. What do you do next?

a) Percutaneous coronary intervention
b) Thrombolysis
c) IV heparin
d) Aspirin and clopidogrel and LMWH
e) Glycoprotein IIb/IIIa inhibitors

a) Percutaneous coronary intervention

- Despite the cocaine use this patient should be referred for PCI. Cocaine thought to lead to MI due to vasospasm, increased Oxygen demand due to its sympathomimetic stimulation and direct toxicity.

63

A 70 year old female with heart failure on ramipril, furosemide and bisoprolol presents with increasing shortness of breath. What is the most appropriate management?

a) Add digoxin
b) Add ISMN
c) Increase furosemide
d) Add spironolactone
e) Stop bisoprolol

d) Add spironolactone

- Digoxin can be useful for symptom control after diuretics and ACE inhibitors have been optimised however have no effect on survival. Spironolactone improves symptoms and improves survival in severe heart failure. Bisoprolol should not be stopped as now not recommended and has been shown to have mortality benefits.

64

A 60 year old gentleman with angina is having increased shortness of breath on exertion. An ECHO shows normal LVF however an ETT is positive. What is the most appropriate management?

a) Nicorandil
b) Peridopril
c) Atenolol
d) Isosorbide mononitrate
e) Amlodipine

c) Atenolol

- Atenolol would be the most appropriate management as these are the mainstay of management. Other drugs listed apart from perindopril are useful if symptoms are not controlled.

65

A 69 year old female with IHD (ischaemic heart disease) has had 3 episodes of collapse. She states she felt dizzy, lost her vision and then she collapsed. She recovers from the episodes quickly and is very well in between. There is no evidence of seizure activity. What do you do next?

a) Echocardiography
b) ETT
c) Coronary angiography
d) 24 hour ECG
e) CT head

d) 24 hour ECG

- This is likely to be a vasovagal syncopal episode with the history given however a 24 hour ECG should be performed due to cardiac history and to rule out a cardiac cause.

66

What characteristic when described with chest pain is most indicative of myocardial ischaemia?

a) Relief with GTN
b) Shortness of breath
c) Light headed
d) Radiation to jaw
e) Palpitations

d) Radiation to jaw

- The description of the pain and history of radiation to jaw or down left arm is the most indicative.

67

A 60 year old man is found to be in AF. It is unknown for how long. What will be useful in rate control but will not lead to reversion to sinus rhythm?

a) Adenosine
b) Sotalol
c) Digoxin
d) Amiodarone
e) Flecainide

c) Digoxin

- Digoxin will rate control but will not lead to cardioversion unlike flecainide, amiodarone and sotalol. Adenosine is not utilised in AF.

68

What is the equation for ejection fraction?

b) EF equals [end diastolic volume (EDV) end systolic volume (ESV)]/ESV
c) EF equals [end diastolic volume (EDV) end systolic volume (ESV)]/HR
d) EF equals [heart rate (HR) × end systolic volume (ESV)]/end diastolic volume (EDV)
e) EF equals [heart rate (HR) × end diastolic volume (EDV)]/end systolic volume (ESV)

a) EF equals [end diastolic volume (EDV) end systolic volume (ESV)]/EDV

69

A 68 year old gentleman who has previously suffered an MI presents with collapse. There was no presyncopal symptoms. On examination there was a displaced apex beat and no focal neurology. An ECG revealed ST elevation in the anterior leads , he was pain free. What is the most likely diagnosis?

a) STEMI
b) TIAs
c) Vasovagal episode
d) Ventricular tachycardia
e) Seizure

a) STEMI

- The patient has a history of STEMI and persistent ST elevation on an ECG which suggests the development of a left ventricular aneurysm. Due to the wall abnormality the patient is at increased risk of developing paroxysmal ventricular tachycardia. There is nil in the history to suggest any of the other diagnosis.

70

What effect do class 1c agents have on the heart?

a) Slow transmission at the AV node
b) Affect the SA node
c) Lengthen the action potential
d) Shorten the action potential
e) Little effect on the action potential

e) Little effect on the action potential

- Class 1c antiarrhythmic agents do not substantially alter the cardiac action potential. Class 1a agents lengthen the action potential and class 1b agents shorten the action potential. Beta blockers affect the SA node slowing the heart rate and calcium channel blockers affect the AV node.

71

An 80 year old female collapsed whilst out shopping. A first aider was on the scene who stated he could not find a pulse for the first few seconds. On examination there was nil of note and an ECG is normal. A 24 hour tape is organised and is normal except for a few ectopics.
What is the most likely diagnosis?

a) Sick sinus syndrome
b) Vasovagal episode
c) Complete heart block
d) Carotid sinus hypersensitivity
e) Transient tachyarrhythmia

d) Carotid sinus hypersensitivity

- It is associated with hypertension and CAD and increasing age. It is an exaggerated response to carotid sinus baroreceptor stimulation i.e. gentle carotid sinus massage leading to at least 3 second asystole (cardioinhibitory response) or BP lowering of at least 50mmHg (vasodepression response) or both. It is increased in those where there may be head or neck tumours, lymphadenopathy or carotid sinus tumours. Vasovagal leads to a normal clinical exam however there is no history of presyncopal features and there was several seconds where there was no pulse present. In the other diagnosis you would expect ECG findings.

72

A 36 year old female has been unwell for several days with a viral illness. She then developed chest pain and shortness of breath. On examination she is hypotensive and tachycardic. There is bibasal crackles. AN ECG reveals non specific ST_T changes and bloods revealed raised inflammatory markers and a raised Troponin I. ECHO reveals dilated and hypokinetic chambers. What is the most likely diagnosis?

a) STEMI
b) Myocarditis
c) Pericarditis
d) Acute mitral regurgitation
e) Infective endocarditis

b) Myocarditis

- Given the history, clinical and ECG findings this patient is likely to be suffering from a myocarditis which can be caused by viral illnesses such as coxsackievirus B, echovirus, poliovirus, adenovirus, mumps, EBV. It is also caused by bacterial such as Staph. aureus or Clostridium perfringens and fungal and parasitic causes. Drugs, toxins and certain autoimmune disease are also known to cause myocarditis. Myocarditis leads to non specific ST changes and s dilated and hypokinetic chambers with segmental wall motion abnormalities. It can also lead to a raised troponin due to inflammation.

73

A 58 year old man who is a heavy smoker presents with severe epigastric pain radiating to his jaw. On examination he is bradycardic and hypotensive and an ECG reveals ST elevation in leads II, III and aVF. What diagnosis fits best with this clinical picture?

a) Unstable angina
b) Pancreatitis
c) Anterolateral STEMI
d) Inferior NSTEMI
e) Inferior STEMI

e) Inferior STEMI

- The history of jaw pain should make you suspicious of cardiac pain despite the epigastric nature initially. The ST elevation in the inferior leads confirms this man is suffering from an inferior STEMI.

74

What auscultatory findings would you expect to find with a left bundle branch block?

a) Reversed splitting of the 2nd heart sound and loud first heart sound
b) Reversed splitting of the 2nd heart sound
c) Normal 2nd heart sound and soft first heart sound
d) Normal first and second heart sounds
e) Fixed splitting of the 2nd heart sound

b) Reversed splitting of the 2nd heart sound

- In LBBB there is a delay in the closure of the aortic valve leading to reversed splitting.
The first heart sound is also softer

75

A 28 year old male has been found to be hypertensive at 190/85 on several occasions and he has been referred and is investigated further. There is a drop of 60mmHg systolic blood pressure from the right brachial to the right femoral. What is the likeliest diagnosis?

a) HOCM
b) Coarctation of aorta
c) Patent ductus arteriosus
d) AS
e) Tetralogy of Fallot

b) Coarctation of aorta

- The likeliest diagnosis is coarctation of the aorta with the finding of difference in BP in radial and femoral artery. The other diagnosis would not lead to the findings above.

76

What is the mechanism of action of clopidogrel?

a) Potentiates factor X
b) Blocks platelet ADP receptors
c) Potentiates antithrombin
d) Glycoprotein IIb/IIIa receptor antagonist
e) Blocks prostaglandin production

b) Blocks platelet ADP receptors

- Clopidogrel works by blocking platelet ADP receptors. Tirofiban blocks glycoprotein IIb/IIIa receptors.

77

B type natriuretic peptide is likely to be normal in which of the following?

a) Unstable angina
b) Acute STEMI
c) Pulmonary embolus
d) Acute mitral regurgitation
e) LVF

a) Unstable angina

- BNP is likely to be normal in unstable angina. It is released when there is an increase in cardiac pressures most commonly secondary to volume distension but also due to obstruction to flow. It causes increase sodium excretion and decreases peripheral vascular resistance. STEMI, LVF and mitral regurgitation lead to increased volume and this release of BNP whilst PE leads to increased cardiac pressure due to obstruction to flow. Unstable angina does not lead to raised intracardiac pressure thus does not cause elevated BNP.

78

A 69 year old gentleman was being treated for a chest infection with antibiotics. He has previous history of myocardial infarction and as well as the current antibiotic course he is also taking aspirin, atorvastatin and perindopril. He then collapses 2 days after the antibiotics began and was taken to A and E. When you examine him he has a BP of 130/80mmHg, heart rate of 80 bpm and he rest of his exam is unremarkable. You notice however on the cardiac monitor he is having short runs of torsade de points. What is the most likely antibiotic that he has been prescribed?

a) Clarithromycin
b) Amoxicillin
c) CO amoxiclav
d) Doxycycline
e) Cephalexin

a) Clarithromycin

- Torsades de Points is a ventricular tachycardia which is polymorphic and occurs with QT prolongation. Macrolides e.g. erythromycin, clarithromycin and quinolones lead to prolongation of QT interval. Erythromycin should be avoided with simvastatin due increased risk of rhabdomyolysis.

79

A 60 year old male presents with general malaise, pyrexia and night sweats. They have a past history of rheumatic heart disease. On examination there is evidence of a pansystolic murmur. Which is a new clinical finding. What organism is the most likely to have caused these symptoms?

a) Staph. Aureus
b) Staph. Epidermidis
c) Strep. Viridans
d) HACEK group
e) MRSA

c) Strep. Viridans

- The most common organism to lead to infective endocarditis on a native valve is Strep Viridans. Staph Aureus and staph epidermidis are most likely to be the causative agents in prosthetic valve endocarditis. HACEK ad MRSA are both more rare causes.