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Question 1
Correct
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A 68-year-old man presents to his general practitioner (GP) with shortness of breath. He describes shortness of breath on exertion and feeling short of breath when he lies flat. He now uses four pillows when sleeping. His past medical history is remarkable for hypertension, hypercholesterolaemia and type II diabetes.
On examination, he has bilateral crepitation, a jugular venous pressure (JVP) of 5 cm and pitting oedema up to his shins. Despite these symptoms, his oxygen saturation is 99% and he is functioning normally at home. He says the symptoms started gradually about 6 months ago and have progressed slowly since.
Which of the following should the GP do first to confirm the provisional diagnosis?Your Answer: Serum brain natriuretic peptide (BNP)
Explanation:The first-line investigation for heart failure in primary care is checking the levels of brain natriuretic peptide (BNP), according to the National Institute for Health and Care Excellence (NICE) guidelines. BNP levels are widely available, non-invasive, quick, and cost-efficient. A normal BNP level can rule out heart failure, but if it is abnormal, an echocardiogram should be done within 6 weeks if it is raised and within 2 weeks if it is very high. Patients with a history of myocardial infarction should have an echocardiogram straightaway. An echocardiogram is the most definitive test diagnostically, as it can accurately assess various parameters. Troponin T level is used to assess myocardial injury resulting from a myocardial infarction, but it is not relevant in chronic heart failure. Myocardial perfusion scans are useful in the diagnosis of coronary artery disease, but they are not the first-line investigation for heart failure. An ECG may be helpful, but it is not sensitive or specific enough to be used as a conclusive diagnostic tool. A chest X-ray can show features of heart failure, but they are usually found in progressed chronic congestive heart failure, which are unlikely to be present at the very first presentation.
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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 60-year-old man comes to the hospital with sudden central chest pain. An ECG is done and shows ST elevation, indicating an infarct on the inferior surface of the heart. The patient undergoes primary PCI, during which a blockage is discovered in a vessel located within the coronary sulcus.
What is the most probable location of the occlusion?Your Answer: Coronary sinus
Correct Answer: Right coronary artery
Explanation:Identifying the Affected Artery in a Myocardial Infarction
Based on the ECG findings of ST elevation in the inferior leads and the primary PCI result of an occlusion within the coronary sulcus, it is likely that the right coronary artery has been affected. The anterior interventricular artery does not supply the inferior surface of the heart and does not lie within the coronary sulcus. The coronary sinus is a venous structure and is unlikely to be the site of occlusion. The right (acute) marginal artery supplies a portion of the inferior surface of the heart but does not run within the coronary sulcus. Although the left coronary artery lies within the coronary sulcus, the ECG findings suggest an infarction of the inferior surface of the heart, which is evidence for a right coronary artery event.
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This question is part of the following fields:
- Cardiology
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Question 3
Correct
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An adolescent with Down's syndrome is being seen at the cardiology clinic due to a heart murmur detected during a routine check-up. It is known that approximately half of infants with Down's syndrome have congenital heart defects, and the prevalence remains high throughout their lifespan. What are the five most frequent types of congenital heart disease observed in individuals with Down's syndrome? Please list them in order of decreasing incidence, starting with the most common cause and ending with the least common cause.
Your Answer: Atrioventricular septal defect, ventricular septal defect, tetralogy of Fallot, atrial septal defect, patent ductus arteriosus
Explanation:Congenital Heart Defects in Down’s Syndrome
Congenital heart defects are common in individuals with Down’s syndrome, with five specific pathologies accounting for approximately 99% of cases. Atrioventricular septal defects and ventricular septal defects occur in roughly a third of cases each, while the remaining third is accounted for by the other three defects. Chromosomal abnormalities, such as trisomy 21, which is commonly associated with Down’s syndrome, can predispose individuals to congenital heart disease. Around 50% of people with Down’s syndrome have one of the five cardiac defects listed above, but the exact cause for this is not yet known.
The development of endocardial cushions is often impaired in individuals with Down’s syndrome, which can lead to defects in the production of the atrial and ventricular septae, as well as the development of the atrioventricular valves. This explains why atrioventricular septal defects are a common congenital defect in Down’s syndrome, as they involve a common atrioventricular orifice and valve. The severity of the defect depends on its size and the positioning of the leaflets of the common atrioventricular valve, which contribute to defining the degree of shunt. Additionally, the type of ventricular septal defects and atrial septal defects that commonly occur in Down’s syndrome can be explained by the impaired development of endocardial cushions. VSDs are usually of the inlet type, while ASDs are more commonly of the prium type, representing a failure of the endocardial cushion to grow in a superior direction.
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This question is part of the following fields:
- Cardiology
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Question 4
Correct
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A 55-year-old man presents to the clinic with complaints of chest pain and difficulty breathing. He had been hospitalized four weeks ago for acute coronary syndrome and was discharged on bisoprolol, simvastatin, aspirin, and ramipril. During the examination, a narrow complex tachycardia is observed. What is the absolute contraindication in this scenario?
Your Answer: Verapamil
Explanation:Verapamil and Beta Blockers: A Dangerous Combination
Verapamil is a type of medication that blocks calcium channels in the heart, leading to a decrease in cardiac output and a slower heart rate. However, it also has negative effects on the heart’s ability to contract, making it a highly negatively inotropic drug. Additionally, it may impair the conduction of electrical signals between the atria and ventricles of the heart.
According to the British National Formulary (BNF), verapamil should not be given to patients who are already taking beta blockers. This is because the combination of these two drugs can lead to dangerously low blood pressure and even asystole, a condition where the heart stops beating altogether.
Therefore, it is important for healthcare professionals to carefully consider a patient’s medication history before prescribing verapamil. If a patient is already taking beta blockers, alternative treatments should be considered to avoid the potentially life-threatening consequences of combining these two drugs.
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This question is part of the following fields:
- Cardiology
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Question 5
Correct
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A 7-year-old girl comes to the clinic complaining of headaches, particularly during times of stress or physical activity. She has no significant medical history. During her neurological exam, no abnormalities are found. However, a systolic murmur is heard along the length of her left sternal edge and spine. Her chest is clear and her blood pressure is 156/88 mmHg in her left arm and 104/68 mmHg in her left leg. An ECG reveals sinus rhythm with evidence of left ventricular hypertrophy. What is the most likely diagnosis?
Your Answer: Coarctation of the aorta
Explanation:Coarctation of the Aorta and its Interventions
Coarctation of the aorta is a condition where the aorta narrows, usually distal to the left subclavian artery. This can cause an asymptomatic difference in upper and lower body blood pressures and can lead to left ventricular hypertrophy. The severity of the restriction varies, with severe cases presenting early with cardiac failure, while less severe cases can go undiagnosed into later childhood.
Interventions for coarctation of the aorta include stenting, excision and graft placement, and using the left subclavian artery to bypass the coarctation. An atrial septal defect and hypertrophic occlusive cardiomyopathy would not cause a blood pressure difference between the upper and lower body. Stress headaches and a flow murmur are not appropriate diagnoses for a child with hypertension, which should be thoroughly investigated for an underlying cause.
In contrast, transposition of the great arteries is a major cyanotic cardiac abnormality that presents in infancy. It is important to diagnose and treat coarctation of the aorta to prevent complications such as left ventricular hypertrophy and cardiac failure.
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This question is part of the following fields:
- Cardiology
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Question 6
Incorrect
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A 50-year-old man who is a known alcoholic is brought to the Emergency Department after being found unconscious. Over several hours, he regains consciousness. His blood alcohol level is high and a head computerised tomography (CT) scan is negative, so you diagnose acute intoxication. A routine chest X-ray demonstrated an enlarged globular heart. An echocardiogram revealed a left ventricular ejection fraction of 45%.
What is the most likely cause of his cardiac pathology, and what might gross examination of his heart reveal?Your Answer: Alcohol and dilation of the left ventricle with normal atria and right ventricle
Correct Answer: Alcohol and dilation of all four chambers of the heart
Explanation:Alcohol and its Effects on Cardiomyopathy: Understanding the Relationship
Alcohol consumption has been linked to various forms of cardiomyopathy, a condition that affects the heart muscle. One of the most common types of cardiomyopathy is dilated cardiomyopathy, which is characterized by the dilation of all four chambers of the heart. This condition results in increased end-diastolic volume, decreased contractility, and depressed ejection fraction. Chronic alcohol use is a significant cause of dilated cardiomyopathy, along with viral infections, toxins, genetic mutations, and trypanosome infections.
Chagas’ disease, caused by trypanosomes, can lead to cardiomyopathy, resulting in the dilation of all four chambers of the heart. On the other hand, alcoholic cardiomyopathy leads to the dilation of all four chambers of the heart, including the atria. Alcohol consumption can also cause concentric hypertrophy of the left ventricle, which is commonly seen in long-term hypertension. Asymmetric hypertrophy of the interventricular septum is another form of cardiomyopathy that can result from alcohol consumption. This condition is known as hypertrophic cardiomyopathy, a genetic disease that can lead to sudden cardiac death in young athletes.
In conclusion, understanding the relationship between alcohol consumption and cardiomyopathy is crucial in preventing and managing this condition. It is essential to limit alcohol intake and seek medical attention if any symptoms of cardiomyopathy are present.
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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-year-old patient is evaluated in the Pre-Assessment Clinic before undergoing elective surgery for varicose veins. The patient is in good health, with the only significant medical history being well-controlled hypertension with lisinopril. During the examination, the clinician hears an early opening snap in diastole when listening to the patient's heart. What is the most probable cause of this finding?
Your Answer: Mitral valve prolapse
Correct Answer: Mitral stenosis
Explanation:Common Heart Murmurs and Their Characteristics
Heart murmurs are abnormal sounds heard during a heartbeat and can indicate underlying heart conditions. Here are some common heart murmurs and their characteristics:
Mitral Stenosis: This condition causes a mid-diastolic murmur that is best heard with the bell of the stethoscope over the apex while the patient is lying in the left lateral position. Severe mitral stenosis can also cause a quiet first heart sound and an early opening snap.
Pulmonary Stenosis: Pulmonary stenosis causes an ejection systolic murmur.
Ventricular Septal Defect: This condition causes a pan-systolic murmur.
Mitral Valve Prolapse: Mitral valve prolapse may cause a mid-systolic click, followed by a late systolic murmur.
Right Bundle Branch Block: This condition is a cause of wide splitting of the second heart sound.
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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 55-year-old woman visits her GP and mentions her diagnosis of heart failure. She expresses interest in learning about medications that can potentially decrease mortality in heart failure. Which drug has been proven to have this effect?
Your Answer: Simvastatin
Correct Answer: Spironolactone
Explanation:Common Medications for Heart Failure: Benefits and Limitations
Heart failure is a chronic condition that affects millions of people worldwide. While there is no cure for heart failure, medications can help manage symptoms and improve quality of life. Here are some common medications used in the treatment of heart failure, along with their benefits and limitations.
Spironolactone: Recent trials have shown that spironolactone can reduce mortality in severe heart failure. This drug works by antagonizing the deleterious effects of aldosterone on cardiac remodeling, rather than its diuretic effect.
Simvastatin: While statins are effective in reducing morbidity and mortality in patients with coronary artery disease, their beneficial effects in heart failure remain inconclusive.
Atenolol: Atenolol has not been shown to be effective in reducing mortality in heart failure and is not used as part of the condition’s management. However, certain beta-blockers like carvedilol, metoprolol, or bisoprolol are recommended in patients who have been stabilized on diuretic and angiotensin-converting enzyme (ACE-I) therapy.
Furosemide: Furosemide is a mainstay in the treatment of both acute and long-term heart failure, particularly for relieving symptoms of fluid overload. However, there is little data to prove that it improves long-term mortality in patients with chronic congestive cardiac failure (CCF).
Digoxin: Digoxin does not decrease mortality in heart failure. Its use is reserved for patients in atrial fibrillation and those who cannot be controlled on an ACE-I, beta-blocker, and loop diuretic. Some studies suggest a decreased rate in CHF-related hospital admissions.
In conclusion, while these medications can help manage symptoms and improve quality of life in heart failure patients, their limitations should also be considered. It is important to work closely with a healthcare provider to determine the best treatment plan for each individual.
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This question is part of the following fields:
- Cardiology
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Question 9
Incorrect
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A 50-year-old woman presents with shortness of breath on exertion, and reports that she sleeps on three pillows at night to avoid shortness of breath. Past medical history of note includes two recent transient ischaemic attacks which have resulted in transient speech disturbance and minor right arm weakness. Other non-specific symptoms include fever and gradual weight loss over the past few months. On auscultation of the heart you notice a loud first heart sound, and a plopping sound in early diastole. General examination also reveals that she is clubbed.
Investigations:
Investigation Result Normal value
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Urea 6.1 mmol/l 2.5–6.5 mmol/l
Creatinine 100 μmol/l 50–120 µmol/l
Haemoglobin 101 g/dl
(normochromic normocytic) 115–155 g/l
Platelets 195 × 109/l 150–400 × 109/l
White cell count (WCC) 11.2 × 109/l 4–11 × 109/l
Erythrocyte sedimentation rate (ESR) 85 mm/h 0–10mm in the 1st hour
Chest X-ray Unusual intra-cardiac calcification
within the left atrium
Which of the following fits best with the likely diagnosis in this case?Your Answer: Infective endocarditis
Correct Answer: Left atrial myxoma
Explanation:Cardiac Conditions: Differentiating Left Atrial Myxoma from Other Pathologies
Left atrial myxoma is a cardiac condition characterized by heart sounds, systemic embolization, and intracardiac calcification seen on X-ray. Echocardiography is used to confirm the diagnosis, and surgery is usually curative. However, other cardiac pathologies can present with similar symptoms, including rheumatic heart disease, mitral stenosis, mitral regurgitation, and infective endocarditis. It is important to differentiate between these conditions to provide appropriate treatment. This article discusses the key features of each pathology to aid in diagnosis.
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This question is part of the following fields:
- Cardiology
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Question 10
Correct
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A 60-year-old man presents to cardiology outpatients after being lost to follow-up for 2 years. He has a significant cardiac history, including two previous myocardial infarctions, peripheral vascular disease, and three transient ischemic attacks. He is also a non-insulin-dependent diabetic. During examination, his JVP is raised by 2 cm, and he has peripheral pitting edema to the mid-calf bilaterally and bilateral basal fine inspiratory crepitations. His last ECHO, performed 3 years ago, showed moderately impaired LV function and mitral regurgitation. He is currently taking bisoprolol, aspirin, simvastatin, furosemide, ramipril, and gliclazide. Which medication, if added, would provide prognostic benefit?
Your Answer: Spironolactone
Explanation:Heart Failure Medications: Prognostic and Symptomatic Benefits
Heart failure is a prevalent disease that can be managed with various medications. These medications can be divided into two categories: those with prognostic benefits and those with symptomatic benefits. Prognostic medications help improve long-term outcomes, while symptomatic medications provide relief from symptoms.
Prognostic medications include selective beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II antagonists, and spironolactone. In the RALES trial, spironolactone was shown to reduce all-cause mortality by 30% in patients with heart failure and an ejection fraction of less than 35%.
Symptomatic medications include loop diuretics, digoxin, and vasodilators such as nitrates and hydralazine. These medications provide relief from symptoms but do not improve long-term outcomes.
Other medications, such as nifedipine, sotalol, and naftidrofuryl, are used to manage other conditions such as angina, hypertension, and peripheral and cerebrovascular disorders, but are not of prognostic benefit in heart failure.
Treatment for heart failure can be tailored to each individual case, and heart transplant remains a limited option for certain patient groups. Understanding the benefits and limitations of different medications can help healthcare providers make informed decisions about the best course of treatment for their patients.
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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 30-year-old woman with rheumatic fever has ongoing shortness of breath following her infection. You suspect she may have mitral stenosis.
What is the most suitable surface anatomical landmark to listen for this murmur?Your Answer: Fifth intercostal space, mid-axillary line
Correct Answer: At the apex beat
Explanation:Surface Locations for Cardiac Auscultation
Cardiac auscultation is a crucial part of a physical examination to assess the heart’s function. The surface locations for cardiac auscultation are essential to identify the specific valve sounds. Here are the surface locations for cardiac auscultation:
1. Apex Beat: The mitral valve is best heard over the palpated apex beat. If it cannot be felt, then it should be assumed to be in the fifth intercostal space, mid-clavicular line.
2. Fifth Intercostal Space, Mid-Axillary Line: This location is too lateral to hear a mitral valve lesion in a non-dilated ventricle.
3. Second Intercostal Space, Left of the Sternum: The pulmonary valve is located in the second intercostal space, left of the sternum.
4. Fourth Intercostal Space, Left of the Sternum: The tricuspid valve is located in the fourth intercostal space, left of the sternum.
5. Xiphisternum: The xiphisternum is not used as a marker for cardiac auscultation, though it is used to guide echocardiography for certain standard views.
Knowing the surface locations for cardiac auscultation is crucial to identify the specific valve sounds and assess the heart’s function accurately.
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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 29-year-old woman presents with sudden-onset palpitation and chest pain that began 1 hour ago. The palpitation is constant and is not alleviated or aggravated by anything. She is worried that something serious is happening to her. She recently experienced conflict at home with her husband and left home the previous day to stay with her sister. She denies any medication or recreational drug use. Past medical history is unremarkable. Vital signs are within normal limits, except for a heart rate of 180 bpm. Electrocardiography shows narrow QRS complexes that are regularly spaced. There are no visible P waves preceding the QRS complexes. Carotid sinus massage results in recovery of normal sinus rhythm.
What is the most likely diagnosis?Your Answer: Sinus tachycardia
Correct Answer: Atrioventricular nodal re-entrant tachycardia
Explanation:Differentiating Types of Tachycardia
Paroxysmal supraventricular tachycardia (PSVT) is a sudden-onset tachycardia with a heart rate of 180 bpm, regularly spaced narrow QRS complexes, and no visible P waves preceding the QRS complexes. Carotid sinus massage or adenosine administration can diagnose PSVT, which is commonly caused by atrioventricular nodal re-entrant tachycardia.
Sinus tachycardia is characterized by normal P waves preceding each QRS complex. Atrial flutter is less common than atrioventricular nodal re-entrant tachycardia and generally does not respond to carotid massage. Atrial fibrillation is characterized by irregularly spaced QRS complexes and does not respond to carotid massage. Paroxysmal ventricular tachycardia is associated with wide QRS complexes.
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This question is part of the following fields:
- Cardiology
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Question 13
Correct
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A 70-year-old patient comes to her doctor for a routine check-up. During the examination, her blood pressure is measured in both arms, and the readings are as follows:
Right arm 152/100
Left arm 138/92
What should be the next step in managing this patient's condition?Your Answer: Ask the patient to start ambulatory blood pressure monitoring
Explanation:Proper Management of High Blood Pressure Readings
In order to properly manage high blood pressure readings, it is important to follow established guidelines. If a patient displays a blood pressure of over 140/90 in one arm, the patient should have ambulatory blood pressure monitoring (ABPM) in order to confirm the presence or lack of hypertension, in accordance with NICE guidelines.
It is important to note that a diagnosis of hypertension cannot be made from one blood pressure recording. However, if hypertension is confirmed, based upon the patients’ age, amlodipine would be the antihypertensive of choice.
When measuring blood pressure in both arms (as it should clinically be done), the higher of the two readings should be taken. Asking the patient to come back in one week to re-record blood pressure sounds reasonable, but it is not in accordance with the NICE guidelines.
Lastly, it is important to note that considering the patients’ age, ramipril is second line and should not be the first choice for treatment. Proper management of high blood pressure readings is crucial for the overall health and well-being of the patient.
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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 65-year-old insurance broker with mitral stenosis is seen in the Cardiology Clinic. He reports increasing shortness of breath on exertion and general fatigue over the past six months. Additionally, he notes swelling in his feet and ankles at the end of the day. What is the first-line intervention for symptomatic mitral stenosis with a mobile undistorted mitral valve and no left atrial thrombus or mitral regurgitation?
Your Answer: Mitral valve repair
Correct Answer: Balloon valvuloplasty
Explanation:Treatment Options for Mitral Valve Disease
Mitral valve disease can be managed through various treatment options depending on the severity and type of the condition. Balloon valvuloplasty is the preferred option for symptomatic patients with mitral stenosis, while mitral valve repair is the preferred surgical management for mitral regurgitation. Aortic valve replacement is an option if the aortic valve is faulty. Mitral valve replacement with a metallic valve requires high levels of anticoagulation, and therefore repair is preferred if possible. The Blalock–Taussig shunt is a surgical method for palliation of cyanotic congenital heart disease. Mitral valve repair may be considered in patients with mitral stenosis if the valve anatomy is unsuitable for balloon valvuloplasty. However, if the patient has severe symptomatic mitral stenosis with signs of heart failure, mitral valve replacement would be the first line of treatment.
Treatment Options for Mitral Valve Disease
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This question is part of the following fields:
- Cardiology
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Question 15
Correct
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A 20-year-old female patient visited her doctor complaining of general malaise, lethargy, and fatigue. She couldn't pinpoint when the symptoms started but felt that they had been gradually developing for a few months. During the physical examination, the doctor detected a murmur and referred her to a cardiologist based on the findings. The cardiac catheterization results are as follows:
Anatomical site Oxygen saturation (%) Pressure (mmHg)
End systolic/End diastolic
Superior vena cava 77 -
Right atrium (mean) 79 7
Right ventricle 78 -
Pulmonary artery 87 52/17
Pulmonary capillary wedge pressure - 16
Left ventricle 96 120/11
Aorta 97 120/60
What is the most accurate description of the murmur heard during the chest auscultation of this 20-year-old woman?Your Answer: A continuous 'machinery' murmur at the left upper sternal edge with late systolic accentuation
Explanation:Characteristics of Patent Ductus Arteriosus
Patent ductus arteriosus is a condition that is characterized by an unusual increase in oxygen saturation between the right ventricle and pulmonary artery. This is often accompanied by elevated pulmonary artery pressures and a high wedge pressure. These data are typical of this condition and can be used to diagnose it. It is important to note that patent ductus arteriosus can lead to serious complications if left untreated, including heart failure and pulmonary hypertension. Therefore, early detection and treatment are crucial for improving outcomes and preventing long-term complications.
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This question is part of the following fields:
- Cardiology
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Question 16
Correct
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What hormone does the heart produce under stressed conditions?
Your Answer: B-type natriuretic peptide (BNP)
Explanation:The cardiovascular system relies on a complex network of hormones and signaling molecules to regulate blood pressure, fluid balance, and other physiological processes. Here are some key players in this system:
B-type natriuretic peptide (BNP): This hormone is secreted by the ventricle in response to stretch, and levels are elevated in heart failure.
Angiotensin II: This hormone is produced mostly in the lungs where angiotensin-converting enzyme (ACE) concentrations are maximal.
C-type natriuretic peptide: This signaling molecule is produced by the endothelium, and not the heart.
Nitric oxide: This gasotransmitter is released tonically from all endothelial lined surfaces, including the heart, in response to both flow and various agonist stimuli.
Renin: This enzyme is released from the kidney, in response to reductions in blood pressure, increased renal sympathetic activity or reduced sodium and chloride delivery to the juxtaglomerular apparatus.
Understanding the roles of these hormones and signaling molecules is crucial for managing cardiovascular health and treating conditions like heart failure.
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This question is part of the following fields:
- Cardiology
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Question 17
Correct
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A 65-year-old man presents to the Emergency Department with sudden onset epigastric discomfort. He has a significant past medical history of hypercholesterolaemia and type II diabetes mellitus, and he is a heavy smoker. On examination, his pulse is 30 bpm; he is hypotensive and has distended neck veins. The chest is clear to auscultation. Initial blood tests reveal an elevated troponin level, and an electrocardiogram (ECG) shows hyperacute T-waves in leads II, III and aVF.
What is the most likely diagnosis?Your Answer: Right/inferior MI
Explanation:Understanding the Different Types of Myocardial Infarction: A Guide to ECG Changes and Symptoms
Myocardial infarction (MI) can occur in different areas of the heart, depending on which artery is occluded. Right/inferior MIs, which account for up to 40-50% of cases, are caused by occlusion of the RCA or, less commonly, a dominant left circumflex artery. Symptoms include bradycardia, hypotension, and a clear chest on auscultation. Conduction disturbances, particularly type II and III heart blocks, are also common. ECG changes include ST-segment elevation in leads II, III, and aVF, and reciprocal ST-segment depression in aVL (± lead I).
Anterolateral MIs are possible, but less likely to present with bradycardia, hypotension, and a clear chest. An anterior MI, caused by occlusion of the LAD, is associated with tachycardia rather than bradycardia.
Other conditions, such as acute pulmonary edema and pulmonary embolism, may present with similar symptoms but have different ECG changes and additional features. Understanding the ECG changes and symptoms associated with different types of MI can help with accurate diagnosis and appropriate treatment.
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This question is part of the following fields:
- Cardiology
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Question 18
Incorrect
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A 63-year-old man presents with increasing shortness of breath on exertion. On examination, bibasilar wet pulmonary crackles are noted with mild bilateral lower limb pitting oedema. His jugular vein is slightly distended. An S4 sound is audible on cardiac auscultation. An electrocardiogram (ECG) shows evidence of left ventricular (LV) hypertrophy. Chest radiography shows bilateral interstitial oedema without cardiomegaly.
Which one of the following findings is most likely to be found in this patient?Your Answer: Impaired LV contraction – increased LV end-diastolic pressure – increased LV end-systolic volume
Correct Answer: Impaired LV relaxation – increased LV end-diastolic pressure – normal LV end-systolic volume
Explanation:Understanding the Different Types of Left Ventricular Dysfunction in Heart Failure
Left ventricular (LV) dysfunction can result in heart failure, which is a clinical diagnosis that can be caused by systolic or diastolic dysfunction, or both. Diastolic dysfunction is characterized by impaired LV relaxation, resulting in increased LV end-diastolic pressure but normal LV end-systolic volume. This type of dysfunction can be caused by factors such as LV hypertrophy from poorly controlled hypertension. On the other hand, impaired LV contraction results in systolic dysfunction, which is characterized by LV dilation, increased LV end-systolic and end-diastolic volumes, and increased LV end-diastolic pressure. It is important to differentiate between these types of LV dysfunction in order to properly diagnose and manage heart failure.
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This question is part of the following fields:
- Cardiology
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Question 19
Correct
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A 65-year-old man presents with a 1-hour history of chest pain and is found to have an acute ST elevation inferior myocardial infarct. His blood pressure is 126/78 mmHg and has a pulse of 58 bpm. He is loaded with anti-platelets, and the cardiac monitor shows second-degree heart block (Wenckebach’s phenomenon).
What would you consider next for this patient?Your Answer: Temporary pacing and primary PCI
Explanation:Management of Heart Block in Acute Myocardial Infarction
Wenckebach’s phenomenon is usually not a cause for concern in patients with normal haemodynamics. However, if it occurs alongside acute myocardial infarction, complete heart block, or symptomatic Mobitz type II block, temporary pacing is necessary. Even with complete heart block, revascularisation can improve conduction if the patient is haemodynamically stable. Beta blockers should be avoided in second- and third-degree heart block as they can worsen the situation. Temporary pacing is required before proceeding to primary percutaneous intervention (PCI). A permanent pacemaker may be necessary for patients with irreversible heart block, but revascularisation should be prioritised as it may improve conduction. The block may be complete or second- or third-degree. If the heart block is reversible, temporary pacing should be followed by an assessment for permanent pacing.
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This question is part of the following fields:
- Cardiology
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Question 20
Correct
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A 27-year-old Asian woman complains of palpitations, shortness of breath on moderate exertion and a painful and tender knee. During auscultation, a mid-diastolic murmur with a loud S1 is heard. Echocardiography reveals valvular heart disease with a normal left ventricular ejection fraction.
What is the most probable valvular disease?Your Answer: Mitral stenosis
Explanation:Differentiating Heart Murmurs: Causes and Characteristics
Heart murmurs are abnormal sounds heard during a heartbeat and can indicate underlying heart conditions. Here are some common causes and characteristics of heart murmurs:
Mitral Stenosis: This condition is most commonly caused by rheumatic fever in childhood and is rare in developed countries. Patients with mitral stenosis will have a loud S1 with an associated opening snap. However, if the mitral valve is calcified or there is severe stenosis, the opening snap may be absent and S1 soft.
Mitral Regurgitation and Ventricular Septal Defect: These conditions cause a pan-systolic murmur, which is not the correct option for differentiating heart murmurs.
Aortic Regurgitation: This condition leads to an early diastolic murmur.
Aortic Stenosis: Aortic stenosis causes an ejection systolic murmur.
Ventricular Septal Defect: As discussed, a ventricular septal defect will cause a pan-systolic murmur.
By understanding the causes and characteristics of different heart murmurs, healthcare professionals can better diagnose and treat underlying heart conditions.
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This question is part of the following fields:
- Cardiology
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Question 21
Correct
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A 28-year-old female presents with palpitations, chest pain, and shortness of breath that radiates to her left arm. These symptoms began six weeks ago after she witnessed her father's death from a heart attack. Over the past decade, she has undergone various investigations for abdominal pain, headaches, joint pains, and dyspareunia, but no significant cause has been identified for these symptoms. What is the probable diagnosis?
Your Answer: Somatisation disorder
Explanation:Somatisation Disorder as the Most Likely Diagnosis
Somatisation disorder is the most probable diagnosis for the given scenario, although it lacks sufficient criteria for a complete diagnosis. This disorder is characterised by recurring pains, gastrointestinal, sexual, and pseudo-neurologic symptoms that persist for years. To meet the diagnostic criteria, the patient’s physical complaints must not be intentionally induced and must result in medical attention or significant impairment in social, occupational, or other important areas of functioning. Typically, the first symptoms appear during adolescence, and the full criteria are met by the age of 30.
Among the other disorders, factitious disorder is the least likely explanation. The other three disorders are possible explanations, but they are not as likely as somatisation disorder.
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This question is part of the following fields:
- Cardiology
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Question 22
Correct
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A 55-year-old woman arrives at the emergency department with a two hour history of central crushing chest pain. She has a history of ischaemic heart disease and poorly controlled diabetes. The ECG shows ST-elevation in V1, V2 and V3, and her serum troponin levels are elevated. What is the most suitable definitive management approach?
Your Answer: Primary percutaneous coronary intervention (PCI)
Explanation:Treatment Options for ST-Elevation Myocardial Infarction (STEMI)
ST-Elevation Myocardial Infarction (STEMI) is a medical emergency that requires immediate intervention. The diagnosis of STEMI is confirmed through cardiac sounding chest pain and evidence of ST-elevation on the ECG. The primary treatment option for STEMI is immediate revascularization through primary percutaneous coronary intervention (PCI) and placement of a cardiac stent.
Therapeutic alteplase, a thrombolytic agent, used to be a common treatment option for STEMI, but it has been largely replaced by primary PCI due to its superior therapeutic outcomes. Aspirin is routinely given in myocardial infarction, and clopidogrel may also be given, although many centers are now using ticagrelor instead.
High-flow oxygen and intravenous morphine may be used for adequate analgesia and resuscitation, but the primary treatment remains primary PCI and revascularization. Routine use of high flow oxygen in non-hypoxic patients with an acute coronary syndrome is no longer advocated.
It is crucial to avoid delaying treatment for STEMI, as it can lead to further deterioration of the patient and increase the risk of cardiac arrhythmia or arrest. Therefore, waiting for troponin results before further management is not an appropriate option. The diagnosis of STEMI can be made through history and ECG findings, and immediate intervention is necessary for optimal outcomes.
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This question is part of the following fields:
- Cardiology
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Question 23
Correct
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An overweight 46-year-old Caucasian male patient attends for the results of a health check arranged by your surgery. He smokes 12 cigarettes a day and is trying to cut down. Alcohol intake is 8 units per week. He tells you that his father underwent a ‘triple bypass’ aged 48 years. His results are as follows:
Total cholesterol : HDL ratio 6
HbA1c: 39 mmol/mol
Urea and electrolytes: normal
Estimated glomerular filtration rate (eGFR): 97 ml/min/1.73m2
Liver function tests: normal
Blood pressure (daytime average on 24-h ambulatory monitor): 140/87
Body mass index (BMI): 25
His QRISK2 10-year cardiovascular risk is calculated at 22.7%.
In addition to assisting with smoking cessation and providing lifestyle advice, what is the most appropriate means of managing his risk?Your Answer: Commence atorvastatin 20 mg once a night and start a calcium channel blocker, review after three months
Explanation:Treatment Plan for a Patient with High Cholesterol and Hypertension
Introduction:
This patient has high cholesterol and hypertension, both of which require immediate attention. In this treatment plan, we will discuss the appropriate medications and monitoring for this patient.Treatment Plan for a Patient with High Cholesterol and Hypertension
Medications:
The patient will start taking atorvastatin 20 mg once a night to address their high cholesterol. After three months, their cholesterol and full lipid profile will be rechecked, and the therapy will be titrated to maintain a total cholesterol of <5. If necessary, the dose may be increased to 40 mg once a night. For hypertension, the patient will start taking a calcium channel blocker as they are over the age of 55. The blood pressure will be monitored regularly, and if it rises above 150/90, additional treatment may be necessary. Monitoring:
The patient’s cholesterol and full lipid profile will be rechecked after three months of treatment with atorvastatin. The aim is to see a 40% reduction in non-HDL cholesterol. If this is not achieved, a discussion of adherence, lifestyle measures, and the possibility of increasing the dose will take place.The patient’s blood pressure will also be monitored regularly. If it rises above 150/90, additional treatment may be necessary.
Conclusion:
This treatment plan addresses both the patient’s high cholesterol and hypertension. By starting atorvastatin and a calcium channel blocker, we can reduce their risk of developing cardiovascular disease. Regular monitoring will ensure that the patient’s cholesterol and blood pressure are under control. -
This question is part of the following fields:
- Cardiology
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Question 24
Incorrect
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A 51-year-old woman with a history of hypothyroidism experiences a collapse during her yoga class. She has been reporting occasional chest pains and difficulty breathing during exercise in the past few weeks. During her physical examination, an ejection systolic murmur is detected at the right upper sternal edge, and her second heart sound is faint. Additionally, she has a slow-rising pulse. What is the most probable cause of her symptoms?
Your Answer: Calcific aortic stenosis
Correct Answer: Bicuspid aortic valve
Explanation:Differentiating Aortic and Mitral Valve Disorders
When evaluating a patient with a heart murmur, it is important to consider the characteristics of the murmur and associated symptoms to determine the underlying valve disorder. In a patient under 70 years old, a slow-rising and weak pulse with a history of collapse is indicative of critical stenosis caused by a bicuspid aortic valve. On the other hand, calcific aortic stenosis is more common in patients over 70 years old and presents differently. Aortic valve regurgitation is characterized by a murmur heard during early diastole and a collapsing pulse, but it is less likely to cause syncope. Mitral valve regurgitation causes a pan-systolic murmur at the apex with a laterally displaced apex beat, but it may present with congestive heart failure rather than syncope or angina. Mitral valve prolapse may cause a mid-systolic click, but a pan-systolic murmur at the apex may be present if there is coexisting mitral regurgitation. By understanding the unique features of each valve disorder, clinicians can make an accurate diagnosis and provide appropriate treatment.
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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 man in his early 60s is undergoing treatment for high blood pressure. During a dental check-up, his dentist informs him that he has gingival hyperplasia. Which medication is the most probable culprit for this condition?
Your Answer: Carvedilol
Correct Answer: Nifedipine
Explanation:Drugs Associated with Gingival Hyperplasia
Gingival hyperplasia is a condition characterized by an overgrowth of gum tissue, which can lead to discomfort, difficulty in maintaining oral hygiene, and even tooth loss. There are several drugs that have been associated with this condition, including Phenytoin, Ciclosporin, and Nifedipine. These drugs are commonly used to treat various medical conditions, such as epilepsy, organ transplant rejection, and hypertension.
According to Medscape, drug-induced gingival hyperplasia is a well-known side effect of these medications. The exact mechanism by which these drugs cause gingival hyperplasia is not fully understood, but it is believed to be related to their effect on the immune system and the production of collagen in the gums.
It is important for healthcare providers to be aware of this potential side effect when prescribing these medications, and to monitor patients for any signs of gingival hyperplasia. Patients who are taking these drugs should also be advised to maintain good oral hygiene and to visit their dentist regularly for check-ups and cleanings.
In summary, Phenytoin, Ciclosporin, and Nifedipine are drugs that have been associated with gingival hyperplasia. Healthcare providers should be aware of this potential side effect and monitor patients accordingly, while patients should maintain good oral hygiene and visit their dentist regularly.
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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 newborn baby is found to have a heart murmur that is later identified as Ebstein's anomaly. Is it possible that a medication taken by the mother during pregnancy could have played a role in causing this congenital heart defect?
Your Answer: Phenytoin
Correct Answer: Lithium
Explanation:Lithium Exposure During Pregnancy Linked to Ebstein’s Anomaly
Exposure to lithium during pregnancy has been found to be linked to the development of Ebstein’s anomaly in newborns. Ebstein’s anomaly is a rare congenital heart defect that affects the tricuspid valve, which separates the right atrium and right ventricle of the heart. This condition can cause a range of symptoms, including shortness of breath, fatigue, and heart palpitations.
Studies have shown that women who take lithium during pregnancy are at an increased risk of having a child with Ebstein’s anomaly. Lithium is commonly used to treat bipolar disorder, and while it can be an effective treatment, it is important for women who are pregnant or planning to become pregnant to discuss the risks and benefits of taking lithium with their healthcare provider.
It is important for healthcare providers to be aware of the potential risks associated with lithium use during pregnancy and to closely monitor pregnant women who are taking this medication. Early detection and treatment of Ebstein’s anomaly can improve outcomes for affected infants.
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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 33-year-old known intravenous drug user presents to your GP clinic with complaints of fatigue, night sweats and joint pain. During the examination, you observe a new early-diastolic murmur. What is the probable causative organism for this patient's condition?
Your Answer: Streptococcus viridans
Correct Answer: Staphylococcus aureus
Explanation:Common Causes of Infective Endocarditis and their Characteristics
Infective endocarditis is a serious condition that can lead to severe complications if left untreated. The most common causative organism of acute infective endocarditis is Staphylococcus aureus, especially in patients with risk factors such as prosthetic valves or intravenous drug use. Symptoms and signs consistent with infective endocarditis include fever, heart murmur, and arthritis, as well as pathognomonic signs like splinter hemorrhages, Osler’s nodes, Roth spots, Janeway lesions, and petechiae.
Group B streptococci is less common than Staphylococcus aureus but has a high mortality rate of 70%. Streptococcus viridans is not the most common cause of infective endocarditis, but it does cause 50-60% of subacute cases. Group D streptococci is the third most common cause of infective endocarditis. Pseudomonas aeruginosa is not the most common cause of infective endocarditis and usually requires surgery for cure.
In summary, knowing the characteristics of the different causative organisms of infective endocarditis can help in the diagnosis and treatment of this serious condition.
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This question is part of the following fields:
- Cardiology
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Question 28
Incorrect
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A 68-year-old woman is admitted to the Cardiology Ward with acute left ventricular failure. The patient is severely short of breath.
What would be the most appropriate initial step in managing her condition?Your Answer: Administer oxygen and secure venous access
Correct Answer: Sit her up and administer high flow oxygen
Explanation:Managing Acute Shortness of Breath: Prioritizing ABCDE Approach
When dealing with acutely unwell patients experiencing shortness of breath, it is crucial to follow the ABCDE approach. The first step is to address Airway and Breathing by sitting the patient up and administering high flow oxygen to maintain normal saturations. Only then should Circulation be considered, which may involve cannulation and administering IV furosemide.
According to the latest NICE guidelines, non-invasive ventilation should be considered as part of non-pharmacological management if simple measures do not improve symptoms.
It is important to prioritize the ABCDE approach and not jump straight to administering medication or inserting a urinary catheter. Establishing venous access and administering medication should only be done after ensuring the patient’s airway and breathing are stable.
If the patient has an adequate systolic blood pressure, iv nitrates such as glyceryl trinitrate (GTN) infusion could be considered to reduce preload on the heart. However, most patients can be treated with iv diuretics, such as furosemide.
In cases of acute pulmonary edema, close monitoring of urine output is recommended, and the easiest and most accurate method is through catheterization with hourly urine measurements. Oxygen should be given urgently if the patient is short of breath.
In summary, managing acute shortness of breath requires a systematic approach that prioritizes Airway and Breathing before moving on to Circulation and other interventions.
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This question is part of the following fields:
- Cardiology
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Question 29
Correct
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A 70-year-old obese woman is admitted with episodic retrosternal chest pain not relieved by rest, for the past 3 weeks. The pain is described as squeezing in nature, and is not affected by meals or breathing. The episodic pain is of fixed pattern and is of same intensity. She has a background of diabetes mellitus, hyperlipidaemia and hypertension. Her family history is remarkable for a paternal myocardial infarction at the age of 63. She is currently haemodynamically stable.
What is the most likely diagnosis in this patient?Your Answer: Acute coronary syndrome
Explanation:Differentiating Acute Coronary Syndrome from Other Cardiac Conditions
The patient in question presents with retrosternal chest pain that is squeezing in nature and unrelated to meals or breathing. This highly suggests a cardiac origin for the pain. However, the episodic nature of the pain and its duration of onset over three weeks point towards unstable angina, a type of acute coronary syndrome.
It is important to differentiate this condition from other cardiac conditions such as aortic dissection, which presents with sudden-onset tearing chest pain that radiates to the back. Stable angina pectoris, on the other hand, manifests with episodic cardiac chest pain that has a fixed pattern of precipitation, duration, and termination, lasting at least one month.
Myocarditis is associated with a constant stabbing chest pain and recent flu-like symptoms or upper respiratory infection. Aortic stenosis may also cause unstable angina, but the most common cause of this condition is critical coronary artery occlusion.
In summary, careful consideration of the pattern, duration, and characteristics of chest pain can help differentiate acute coronary syndrome from other cardiac conditions.
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This question is part of the following fields:
- Cardiology
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Question 30
Correct
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A 42-year-old man felt dizzy at work and later had a rhythm strip (lead II) performed in the Emergency Department. It reveals one P wave for every QRS complex and a PR interval of 240 ms.
What does this rhythm strip reveal?Your Answer: First-degree heart block
Explanation:Understanding Different Types of Heart Block
Heart block is a condition where the electrical signals that control the heartbeat are disrupted, leading to an abnormal heart rhythm. There are different types of heart block, each with its own characteristic features.
First-degree heart block is characterized by a prolonged PR interval, but with a 1:1 ratio of P waves to QRS complexes. This type of heart block is usually asymptomatic and does not require treatment.
Second-degree heart block can be further divided into two types: Mobitz type 1 and Mobitz type 2. Mobitz type 1, also known as Wenckebach’s phenomenon, is characterized by a progressive lengthening of the PR interval until a QRS complex is dropped. Mobitz type 2, on the other hand, is characterized by intermittent P waves that fail to conduct to the ventricles, leading to intermittent dropped QRS complexes. This type of heart block often progresses to complete heart block.
Complete heart block, also known as third-degree heart block, occurs when there is no association between P waves and QRS complexes. The ventricular rate is often slow, reflecting a ventricular escape rhythm as the ventricles are no longer controlled by the sinoatrial node pacemaker. This type of heart block requires immediate medical attention.
Understanding the different types of heart block is important for proper diagnosis and treatment. If you experience any symptoms of heart block, such as dizziness, fainting, or chest pain, seek medical attention right away.
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This question is part of the following fields:
- Cardiology
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