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Question 1
Incorrect
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A 13 yr. old boy presented with difficulty in breathing on exertion. According to his mother who was also present, his exercise tolerance has been gradually worsening for the past weeks. It has reached the point where he is unable to participate in his weekly soccer match. Cardiac catherization was performed and the results are given below:
(Anatomical site vs Oxygen saturation (%)vs Pressure (mmHg))
Superior vena cava:
73
,–.
Right atrium:
71,
6.
Right ventricle:
72,
–.
Pulmonary artery:
86,
53/13.
PCWP:
–,
15.
Left ventricle:
97,
111/10.
Aorta:
96,
128/61.
Which of the following is the diagnosis?Your Answer:
Correct Answer: Patent ductus arteriosus
Explanation:The oxygen saturation in the pulmonary artery is higher than that of the right ventricle. The pressure of the pulmonary artery and of the PCWP are also high. So patent ductus arteriosus is highly suggestive.
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This question is part of the following fields:
- Cardiology
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Question 2
Incorrect
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A 42 yr. old previously well woman presented with acute severe central chest pain for the past 2 hours. She has a family history of premature coronary artery disease. Her husband passed away recently due to prostate cancer. On examination her blood pressure was 130/80 mmHg and pulse rate was 80 bpm. Her ECG showed ST segment elevation and her troponin was slightly elevated. Emergency angiogram revealed slight wall irregularities with no luminal obstruction. Cardiovascular MR showed an apical ballooning of the myocardium resembling an octopus pot. Which of the following is the most likely cause for the ST segment elevation?
Your Answer:
Correct Answer: Takotsubo cardiomyopathy
Explanation:Causes for ST segment elevation other than myocardial infarction
Natural variants
-Early repolarization
-Left ventricular hypertrophy and hypertrophic cardiomyopathy
-Left bundle branch block
Artefacts
-Leads mispositioning
-Electrical cardioversion
Cardiovascular diseases
-Pericarditis/ Myocarditis
-Aortic dissection
-Prinzmetal’s angina
-Takotsubo Cardiomyopathy
-Brugada Syndrome and arrhythmogenic right ventricular cardiomyopathy/dysplasia
Pulmonary diseases
-Pulmonary thromboembolism
-Pneumothorax
-Atelectasis and pulmonary metastases
Gastrointestinal diseases
-Acute pancreatitis
-Acute cholecystitis
Other conditions
-Hyperkalaemia
-Drug induced ST segment elevation (e.g. – clozapine)
-Haemorrhagic cerebrovascular diseaseCoronary artery disease and myocardial infarction can be excluded with a negative angiogram and a slightly elevated troponin. Hypertrophic cardiomyopathy can be excluded with cardiovascular MR findings. Left ventricular aneurysm usually occurs following a myocardial infarction, but there is no positive history for that. The characteristic findings on cardiovascular MR confirms the diagnosis of Takotsubo cardiomyopathy.
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This question is part of the following fields:
- Cardiology
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Question 3
Incorrect
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A 52 yr. old female who was a smoker, with a history of asymptomatic atrial septal defect (ASD) presented with difficulty in breathing on exertion and ankle oedema for the past 2 weeks. She has defaulted on her follow up for ASD. On examination she was cyanosed and clubbing was noted. Her pulse rate was 92 and blood pressure was 100/60 mmHg. Echocardiography revealed a dilated right ventricle of the heart. The right ventricular pressure was 90 mmHg. Significant tricuspid and pulmonary regurgitation were also noted. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Eisenmenger’s syndrome
Explanation:According to echocardiography findings pulmonary pressure is closer to systemic blood pressure and it is evidence of pulmonary hypertension. Because of the reversal of shunt due to pulmonary hypertension, cyanosis and clubbing have developed. So the most probable diagnosis is Eisenmenger’s syndrome.
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This question is part of the following fields:
- Cardiology
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Question 4
Incorrect
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A 62 yr. old male presented with worsening breathlessness and fatiguability. On examination there was bilateral ankle swelling and pulsatile liver. Auscultation revealed a pansystolic murmur best heard at the lower left sternal border. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Tricuspid regurgitation
Explanation:All the clinical features are suggestive of tricuspid regurgitation. The pansystolic murmur of mitral regurgitation is best heard at the apex.
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This question is part of the following fields:
- Cardiology
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Question 5
Incorrect
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A 55 yr. old female with a history of hypertension presented with severe central chest pain for the past one hour, associated with sweating and vomiting. Her ECG showed ST elevation myocardial infarction, evident in leads V2-V4. Which of the following is an absolute contraindication for thrombolysis?
Your Answer:
Correct Answer: Intracranial neoplasm
Explanation:Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial haemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months -
This question is part of the following fields:
- Cardiology
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Question 6
Incorrect
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Which of the following features of the jugular venous waveform indicates the closure of the tricuspid valve?
Your Answer:
Correct Answer: c wave
Explanation:The a wave indicates atrial contraction. The c wave indicates ventricular contraction and resulting bulging of the tricuspid valve into the right atrium during isovolumetric systole. The v wave indicates venous filling. The x descent indicates the atrium relaxation and the movement of tricuspid valve downward. The y descent indicates the filling of the ventricle after the opening of the tricuspid valve.
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This question is part of the following fields:
- Cardiology
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Question 7
Incorrect
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A 54 yr. old patient presented with a dry cough after starting treatment for hypertension. He was prescribed ramipril 2.5mg and the dry cough started after that, which disturbed his sleep. His blood pressure was normal. Which of the following is the most appropriate management?
Your Answer:
Correct Answer: Stop the ramipril and prescribe candesartan
Explanation:ACE inhibitors are known to cause a dry cough and they should be stopped, to settle the cough. The next drug of choice is an angiotensin receptor blocker such as candesartan.
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This question is part of the following fields:
- Cardiology
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Question 8
Incorrect
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A 60 yr. old man presented with severe central chest pain for the last 2 hours. He was on insulin for diabetes mellitus and he was dependent on haemodialysis because of end stage renal failure. He had undergone haemodialysis 48 hours prior to this presentation. His ECG showed an acute inferior myocardial infarction. Despite thrombolysis and other appropriate treatment, he continued to have chest pain after 6 hours from the initial presentation. His blood pressure was 88/54 mmHg and he had bibasal crepitations. His investigation results are given below.
Serum sodium 140 mmol/l (137-144),
Serum potassium 6.6 mmol/l (3.5-4.9),
Serum urea 50 mmol/l (2.5-7.5),
Serum creatinine 940 μmol/l (60-110),
Haemoglobin 10.2g/dl (13.0-18.0),
Troponin T >24 g/l (<0.04),
Left ventricular ejection fraction was 20%.
What is the most appropriate management for this patient?Your Answer:
Correct Answer: Coronary angiography and rescue PCI
Explanation:According to the history the patient has cardiogenic shock and pulmonary oedema. On-going ischaemia is indicated by persisting symptoms. So the most appropriate management is coronary angiography and rescue PCI. There are no indications for blood transfusion at this moment and it will aggravate the pulmonary oedema. Haemodialysis, beta blockers and furosemide cannot be given due to low blood pressure.
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This question is part of the following fields:
- Cardiology
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Question 9
Incorrect
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Which of the following is not associated with atrial myxoma?
Your Answer:
Correct Answer: J wave on ECG
Explanation:J waves in an ECG is associated with hypothermia, hypercalcemia, the Brugada syndrome, and idiopathic ventricular fibrillation. The other responses are all associated with atrial myxoma
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This question is part of the following fields:
- Cardiology
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Question 10
Incorrect
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A 30 yr. old male presented with exercise related syncope and dyspnoea for 2 weeks. His father passed away at the age of 40, due to sudden cardiac death. His ECG showed left ventricular hypertrophy with widespread T wave inversions. Which of the following is the most appropriate next investigation to confirm the diagnosis?
Your Answer:
Correct Answer: Transthoracic echo
Explanation:The most likely diagnosis is hypertrophic obstructive cardiomyopathy which is suggestive by the history, positive family history and ECG findings. Two-dimensional echocardiography is diagnostic for hypertrophic cardiomyopathy. In general, a summary of echocardiography findings includes abnormal systolic anterior leaflet motion of the mitral valve, LV hypertrophy, left atrial enlargement, small ventricular chamber size, septal hypertrophy with septal-to-free wall ratio greater than 1.4:1, mitral valve prolapse and mitral regurgitation, decreased midaortic flow, and partial systolic closure of the aortic valve in midsystole.
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This question is part of the following fields:
- Cardiology
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Question 11
Incorrect
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A 70 yr. old male patient presented with chronic congestive heart failure. Which of the following is the most important factor to consider when prescribing drugs for this patient?
Your Answer:
Correct Answer: Administration of a B-blocker reduces the time spent in hospital
Explanation:It is proven that spironolactone has survival benefits and loop diuretics only give symptomatic relief. Beta blockers are however, known to improve exercise tolerance, left ventricular function and reduce symptoms. They also reduce the mortality associated with heart failure. So administration of beta blockers will reduce the time spent in hospital by improving symptoms.
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This question is part of the following fields:
- Cardiology
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Question 12
Incorrect
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A 72 yr. old male presented to the Emergency Department with a broad complex tachycardia. Which of the following features is more suggestive that this has resulted because of a supraventricular tachycardia (SVT) rather than a ventricular tachycardia (VT)?
Your Answer:
Correct Answer: Absence of QRS concordance in chest leads on ECG
Explanation:To differentiate ventricular tachycardia (VT) from supraventricular tachycardia (SVT) with aberrant conduction the following electrocardiographic features should be looked for:
Evidence of preceding atrial activity for SVT. Oesophageal leads are helpful if P waves are hidden in the QRS complex.
QRS duration more than 140 ms for VT.
QRS morphology: Features of QRS morphology that favour SVT are RBBB or triphasic patterns like rSR in V1 and qRS in V6. Monophasic pattern like R or qR in V1 and rS or QS in V6 or multiple morphology QRS complexes favour VT.
AV dissociation for VT. -
This question is part of the following fields:
- Cardiology
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Question 13
Incorrect
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A 60 yr. old previously well male patient was admitted with acute severe central chest pain associated with excessive sweating and nausea for the past 45 minutes. On examination he was found to have xanthelasma. His blood pressure was 170/100 mmHg and pulse rate was 104 bpm. His ECG showed ST elevation more than 2mm in leads II, III and aVF. His troponin T was 120 ng/ml. His FBC and renal functions were normal. He was given aspirin, clopidogrel, morphine and IV 5mg of atenolol. Which of the following is the most appropriate next step?
Your Answer:
Correct Answer: Immediate referral to cardiologist for primary angioplasty
Explanation:The diagnosis is acute inferior ST elevation myocardial infarction so the most appropriate management is primary angioplasty.
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This question is part of the following fields:
- Cardiology
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Question 14
Incorrect
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A 20 yr. old male presented after an episode where he had collapsed. This was the second time he has collapsed during the past 3 weeks. His father passed away at the age of 40 due to sudden cardiac death. Echocardiography showed evidence of hypertrophic cardiomyopathy. His 24 hr ECG revealed several short runs of non sustained ventricular tachycardia (VT). Which of the following is the most appropriate management for this patient?
Your Answer:
Correct Answer: Implantable cardiovertor defibrillator
Explanation:This patient has a high risk of sudden cardiac death due to a strong family history and non sustained VT. So the most appropriate management is implantable cardiovertor defibrillator.
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This question is part of the following fields:
- Cardiology
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Question 15
Incorrect
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A 68 yr. old male with history of poorly controlled hypertension was admitted with shortness of breath on exertion, orthopnoea for three months. He was diagnosed with congestive cardiac failure and was started on digoxin 62.5 μg daily, furosemide 80mg daily and amiloride 10mg daily. On admission his lab results showed that his serum urea was 6 mmol/L and serum creatinine was 115 μmol/L. One month later he came for a follow up consultation. On examination he had bilateral ankle oedema. His blood pressure was 138/90 mmHg and pulse rate was 92 bpm. His JVP was not elevated. His apex beat was displaced laterally and he had a few bibasal crepitations on auscultation. There were no cardiac murmurs. His investigation results revealed the following:
Serum sodium 143 mmol/L (137-144),
Serum potassium 3.5 mmol/L (3.5-4.9),
Serum urea 8 mmol/L (2.5-7.5),
Serum creatinine 140 μmol/L (60-110),
Serum digoxin 0.7 ng/mL (1.0-2.0).
CXR showed cardiomegaly and a calcified aorta. ECG showed left ventricular hypertrophy.
Which of the following is the most appropriate next step in the management of this patient?Your Answer:
Correct Answer: Add an ACE inhibitor to the current regimen
Explanation:From the given history the patient has NYHA grade III heart failure. He can be safely started on an ACE inhibitor as his serum potassium was towards the lower limit. As there an impairment of renal function, his urea, creatinine and serum electrolytes should be closely monitored after commencing an ACE inhibitor. Adding atenolol will not have any clinical benefit. Increasing the digoxin dose is not needed as the patient is in sinus rhythm. Increasing furosemide will only have symptomatic relief.
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This question is part of the following fields:
- Cardiology
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Question 16
Incorrect
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A 60 yr. old male smoker and a known hypertensive presented with central chest pain radiating to the back. On examination he was tachycardic and hypotensive. His ECG showed inferior ST elevation and his transoesophageal echocardiogram showed a double lumen in the ascending aorta. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Dissecting aortic aneurysm
Explanation:The classic history in this high risk patient is suggestive of a dissecting aortic aneurysm. His transoesophageal echocardiogram confirms the diagnosis. ST elevation in ECG is probably due to the extension of the dissection of the aorta which results in compromised coronary blood supply.
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This question is part of the following fields:
- Cardiology
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Question 17
Incorrect
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A 50 yr. old smoker with a history of hypertension presented with acute severe chest pain and acute myocardial infarction was diagnosed. Which of the following is a contraindication for thrombolysis?
Your Answer:
Correct Answer: History of likely ischaemic stroke within the past month
Explanation:Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial haemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months -
This question is part of the following fields:
- Cardiology
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Question 18
Incorrect
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A 50 yr. old male with a history of type II diabetes mellitus and hypertension presented with exertional dyspnoea and chest pain for 2 weeks. On examination his blood pressure was 145/80 mmHg. On auscultation reversed splitting of the second heart sound and bibasal crepitations were detected. What would be the most likely finding on his ECG?
Your Answer:
Correct Answer: Left bundle branch block
Explanation:When closure of the pulmonary valve occurs before the aortic valve, reversed splitting occurs. The causes of reversed splitting are aortic stenosis, hypertrophic cardiomyopathy, left bundle branch block (LBBB), and a ventricular pacemaker.
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This question is part of the following fields:
- Cardiology
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Question 19
Incorrect
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A 60 year old male patient with a history of heavy smoking was admitted complaining of acute severe central chest pain for the past one hour. His blood pressure was 150/90 mmHg and pulse rate was 88 bpm. His peripheral oxygen saturation was 93%. ECG showed ST elevation > 2mm in lead II, III and aVF. He was given loading doses of aspirin, clopidogrel and atorvastatin and face mask oxygen was given. Which one of the following investigations should be done and then depending on result, definitive treatment can be initiated?
Your Answer:
Correct Answer: None
Explanation:The history and ECG findings are adequate to begin cardiac revascularization of this patient. There is no need for cardiac markers to confirm the diagnosis. Further delay in starting definite treatment is not recommended.
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This question is part of the following fields:
- Cardiology
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Question 20
Incorrect
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Which of the following is the mechanism of action of bivalirudin in acute coronary syndrome?
Your Answer:
Correct Answer: Reversible direct thrombin inhibitor
Explanation:Bivalirudin is a competitive, direct thrombin inhibitor. It inhibits both free and clot-bound thrombin and thrombin-induced platelet aggregation. Thrombin enables fibrinogen conversion to fibrin during the coagulation cascade. So inhibition of fibrinogen conversion to fibrin inhibits thrombus development.
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This question is part of the following fields:
- Cardiology
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Question 21
Incorrect
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Which of the following is not associated with right axis deviation?
Your Answer:
Correct Answer: Wolf-Parkinson-White syndrome with right-sided accessory pathway
Explanation:Causes for right axis deviation:
-Right ventricular hypertrophy and Left posterior fascicular block
-Lateral myocardial infarction.
-Acute or chronic lung diseases: Pulmonary embolism, pulmonary hypertension, chronic obstructive pulmonary disease (COPD), cor pulmonale.
-Congenital heart disease (e.g., dextrocardia, secundum atrial septal defect).
-Wolff-Parkinson-White syndrome.
-Ventricular ectopic rhythms (e.g., ventricular tachycardia). -
This question is part of the following fields:
- Cardiology
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Question 22
Incorrect
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A 25 yr. old male presented with an episode of syncope. His examination findings were normal. He gave a history of sudden cardiac death of a close relative. His ECG showed incomplete right bundle-branch block and ST-segment elevations in the anterior precordial leads. What is the most probable diagnosis?
Your Answer:
Correct Answer: Brugada syndrome
Explanation:Brugada syndrome is an autosomal dominant disorder characterized by sudden cardiac death. The positive family history and characteristic ECG findings are in favour of Brugada syndrome. Usually the physical findings are normal.
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This question is part of the following fields:
- Cardiology
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Question 23
Incorrect
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A 30 yr. old male was brought in with a history of a stab injury to left chest. He was complaining of chest pain. On examination he was tachycardic, hypotensive and had an elevated JVP, pulsus paradoxus and muffled heart sounds. Respiratory examination was unremarkable. Which of the following is most probable diagnosis?
Your Answer:
Correct Answer: Cardiac tamponade
Explanation:Becks triad (hypotension, elevated systemic venous pressure, often with jugular venous distention and muffled heart sounds) is a characteristic collection of clinical findings found in cardiac tamponade. Pulsus paradoxus is also associated with it. The history and clinical findings in this scenario are compatible with the diagnosis of cardica tamponade. The normal respiratory examination excludes tension pneumothorax.
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This question is part of the following fields:
- Cardiology
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Question 24
Incorrect
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A 72 yr. old male with a history of type II diabetes mellitus and hypertension for 15 years, presented with gradual onset difficulty in breathing on exertion and bilateral ankle swelling for the past 3 months. On examination he had mild ankle oedema. His JVP was not elevated. His heart sounds were normal but he had bibasal crepitations on auscultation. Which of the following clinical signs has the greatest sensitivity in detecting heart failure in this patient?
Your Answer:
Correct Answer: Third heart sound
Explanation:The presence of a third heart sound is the most sensitive indicator of heart failure. All of the other signs can be found in heart failure with varying degrees.
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This question is part of the following fields:
- Cardiology
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Question 25
Incorrect
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A 28 yr. old primigravida in her 24th week of pregnancy presented with a history of palpitations, which are fast and regular. She doesn't complain of any episodes of collapse. On examination she was well, pulse rate was 102 bpm, which was regular and her blood pressure was 110/70 mmHg. Her JVP was not elevated. Heart sounds were normal. ECH showed sinus tachycardia. Which of the following can be expected because of the physiological changes which occur in the boy during pregnancy?
Your Answer:
Correct Answer: Tachycardia
Explanation:The cardiovascular alterations which occur during pregnancy are for the optimal growth and development of the foetus and help to protect the mother from the risks of delivery, such as haemorrhage. The changes are characterized by an increased vascular volume, cardiac output, and heart rate, with a marked fall in vascular resistance and reduction in blood pressure.
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This question is part of the following fields:
- Cardiology
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Question 26
Incorrect
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A 55 yr. old male with a history of myocardial infarction 4 years ago, was admitted with a history of fever for the past 2 weeks. On investigation, his echocardiography revealed a small vegetation around the mitral valve. His blood culture was positive for Streptococcus viridans. Which of the following is the most appropriate antibiotic therapy?
Your Answer:
Correct Answer: IV benzylpenicillin
Explanation:According to the American Heart Association (AHA) penicillin-susceptible S viridans, S bovis, and other streptococci (MIC of penicillin of ≤0.1 mcg/mL) should be treated with penicillin G or ceftriaxone or penicillin G + a gentamicin combination or vancomycin (if allergy to penicillin).
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This question is part of the following fields:
- Cardiology
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Question 27
Incorrect
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A 34 yr. old male presented with exertional dyspnoea and chest pain for the past 2 weeks. On examination there was a mid-systolic murmur which is best heard at the apex and double apical impulse. His ECG showed left ventricular hypertrophy (LVH). What is the risk factor which would be most indicative of the potential for sudden death in this patient?
Your Answer:
Correct Answer: Degree of left ventricular hypertrophy
Explanation:The history is suggestive of hypertrophic obstructive cardiac myopathy. The degree of left ventricular hypertrophy is strongly associated with sudden cardiac death.
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This question is part of the following fields:
- Cardiology
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Question 28
Incorrect
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From the following responses, what is the commonest cardiovascular abnormality associated with Marfan's syndrome of an adult?
Your Answer:
Correct Answer: Aortic root dilatation
Explanation:The main cardiovascular manifestations associated with Marfan’s syndrome are aortic dilatation and mitral valve prolapse.
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This question is part of the following fields:
- Cardiology
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Question 29
Incorrect
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Which of the following is not an indication for an implantable cardiac defibrillator?
Your Answer:
Correct Answer: Wolff-Parkinson White syndrome
Explanation:Class I indications (i.e., the benefit greatly outweighs the risk, and the treatment should be administered): -Structural heart disease, sustained VT
-Syncope of undetermined origin, inducible VT or VF at electrophysiologic study (EPS)
-Left ventricular ejection fraction (LVEF) ≤35% due to prior MI, at least 40 days post-MI, NYHA class II or III
-LVEF ≤35%, NYHA class II or III
-LVEF ≤30% due to prior MI, at least 40 days post-MI
-LVEF ≤40% due to prior MI, inducible VT or VF at EPSClass IIa indications (i.e., the benefit outweighs the risk and it is reasonable to administer the treatment):
-Unexplained syncope, significant LV dysfunction, nonischaemic cardiomyopathy
-Sustained VT, normal or near-normal ventricular function
-Hypertrophic cardiomyopathy with 1 or more major risk factors
-Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) with 1 or more risk factors for sudden cardiac death (SCD)
-Long QT syndrome, syncope or VT while receiving beta-blockers
-Nonhospitalized patients awaiting heart transplant
-Brugada syndrome, syncope or VT
-Catecholaminergic polymorphic VT, syncope or VT while receiving beta-blockers
-Cardiac sarcoidosis, giant cell myocarditis, or Chagas disease -
This question is part of the following fields:
- Cardiology
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Question 30
Incorrect
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A 60 yr. old male presented with ventricular tachycardia which was successfully cardioverted. To check whether he had prolonged QT interval, which of the following is the most appropriate method to measure the QT interval in ECG?
Your Answer:
Correct Answer: Time between the start of the Q wave and the end of the T wave
Explanation:The QT interval is the time from the start of the Q wave to the end of the T wave. It represents the time taken for ventricular depolarisation and repolarisation. The QT interval should be measured in either lead II or V5-6.
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This question is part of the following fields:
- Cardiology
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SESSION STATS - PERFORMANCE PER SPECIALTY
