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Question 1
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: Aortic dissection
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 2
Correct
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A 60 yr. old female presented with difficulty in breathing. What is the clinical sign that will indicate the presence of established pulmonary hypertension?
Your Answer: Raised jugular venous pressure
Explanation:A prominent A wave is observed in the jugular venous pulse and this indicates the presence of established pulmonary hypertension. In addition the pulmonic component of the second heart sound (P2) may be increased and the P2 may demonstrate fixed or paradoxical splitting. The signs of right ventricular failure include a high-pitched systolic murmur of tricuspid regurgitation, hepatomegaly, a pulsatile liver, ascites, and peripheral oedema.
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This question is part of the following fields:
- Cardiology
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Question 3
Incorrect
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Which of the following is suggestive of co-existence of mitral regurgitation and mitral stenosis?
Your Answer: Raised JVP
Correct Answer: Displaced apex beat
Explanation:Apex beat displacement is caused by mitral regurgitation and because it is not found in mitral stenosis, it is suggestive of mixed mitral disease. The other given responses occur in mitral stenosis.
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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 30 yr. old primigravida in her 23rd week of pregnancy presented with palpitations. Her ECG showed supraventricular tachycardia (SVT). 15 minutes after admission the SVT spontaneously reverted to sinus rhythm. She had two episodes of SVT later which were associated with palpitations. Which of the following is the most appropriate treatment for this presentation?
Your Answer: Metoprolol
Correct Answer: Verapamil
Explanation:Both long-acting calcium channel blockers and beta blockers improve symptoms of patients with SVT. Verapamil does not have adverse maternal or fetal side effects which would suggest that the use of verapamil in the treatment of supraventricular arrhythmias in pregnancy is safe and effective. Beta blockers are associated with intrauterine fetal growth restriction.
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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 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: 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 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: a wave
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
Correct
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A 40 yr. old female presented with palmar xanthomas and tuberoeruptive xanthomas on her elbows and knees. Which of the following is the most probable diagnosis?
Your Answer: Type III hyperlipoproteinaemia
Explanation:Palmar xanthomas and tuberoeruptive xanthomas are found in type III hyperlipoproteinemia (dysbetalipoproteinemia,broad-beta disease, remnant removal disease)
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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 70 yr. old female was brought in by the paramedics after she collapsed whilst shopping. She has a tachycardia of 150 bpm and her BP is 100/60 mmHg. Her ECG showed a broad complex tachycardia. Which of the following is more suggestive of a ventricular tachycardia (VT) over a supraventricular tachycardia (SVT) with aberrant conduction?
Your Answer: A corrected QT interval of 420ms
Correct Answer: Atrioventricular dissociation
Explanation:To differentiate VT from 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 9
Correct
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A 54 yr. old heavy smoker presented with acute chest pain for 3 hrs which associated with excessive sweating and vomiting. His past medical history was unremarkable but his father has passed away due to a heart attack at the age of 50. Examination findings were normal and ECG was also normal. He was pain free after 12 hours from admission. What is the most appropriate investigation that cab be done at this moment?
Your Answer: Troponin T
Explanation:The positive family history and the smoking make him an ideal candidate for a myocardial infarction. The chest pain is also a suggestive symptom. So troponin is needed to rule out MI.
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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 70 yr. old man underwent temporary transvenous pacing. While in the coronary care unit he developed pre-syncope. His pulse rate was 30 bpm. His ECG showed pacing spikes which were not related to QRS complexes. What is the most appropriate action that can be taken?
Your Answer: Arrange for an urgent permanent pacemaker
Correct Answer: Increase the pacing voltage to a maximum
Explanation:Pacemaker spikes on the ECG indicate that pacemaker is functioning. The most probable cause for this presentation is the change of the position of the tip of the pacing wire. Increasing the voltage will solve the problem. If it works, repositioning of the pacing wire should be done.
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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: Angiotensin II-receptor antagonists have a better response rate than ACE inhibitors
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 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: History of peptic ulcer disease
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 13
Incorrect
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A 25 yr. old female presented with a history of sudden collapse. She had been playing netball and had suddenly collapsed. This collapse had been accompanied by a brief period of loss of consciousness. She experienced palpitations for a brief period prior to losing consciousness. On examination her BP was 120/70 mmHg and pulse rate was 72 bpm, which was regular. The rest of the examination was also normal. She had similar experience of collapse, about two years ago. She was well except for these two incidents and she has not been on any medication. All the investigations done at the first presentation (2 years ago), including FBC, ECG and echocardiography were normal. Her ECG done at this presentation revealed QT prolongation of 0.50 s. FBC, CXR and other investigations were normal. Which of the following is the best way of managing this patient?
Your Answer: Start her on a calcium channel blocker
Correct Answer: Start on a beta-blocker
Explanation:Beta-blockers are drugs of choice for patients with LQTS. The protective effect of beta-blockers is related to their adrenergic blockade, which diminishes the risk of cardiac arrhythmias. They may also reduce the QT interval in some patients.
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This question is part of the following fields:
- Cardiology
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Question 14
Correct
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Which one of the following responses is the least likely to be associated with primary pulmonary hypertension?
Your Answer: Recurrent pulmonary embolism
Explanation:Connective-tissue diseases, liver cirrhosis, exposure to anorexigens and likely other alpha-adrenergic stimulants [e.g., cocaine, amphetamines] and HIV infection are associated with primary pulmonary hypertension. Recurrent pulmonary emboli, chronic lung diseases, left heart diseases are causes for secondary pulmonary hypertension. Pulmonary vascular hypertension after use of fenfluramine is rarely reported.
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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 42 yr. old male patient who was on enalapril for hypertension presented with generalized body weakness. Investigations revealed hyperkalaemia. Which of the following can be expected in his ECG?
Your Answer: Flattened T waves
Correct Answer: Tall, tented T waves
Explanation:In hyperkalaemia the ECG will show tall, tented T waves as well as small P waves and widened QRS complexes.Â
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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 35 yr. old female with systemic lupus erythematosus (SLE) was brought to Casualty, complaining of chest pain and worsening difficulty in breathing for the past 36 hrs. On examination she was tachypnoeic, her BP was 85/65 mmHg and peripheral oxygen saturation was 98% on air. Her cardiac examination was normal but her jugular venous pressure was elevated. She didn't have ankle oedema. Her ECG showed sinus tachycardia and her CXR showed clear lung fields with a slightly enlarged heart. Which of the following is the most appropriate next step?
Your Answer: Start ionotropic agents
Correct Answer: Urgent transthoracic echocardiogram
Explanation:Acute breathlessness in SLE can be due to a pericardial effusion or a pulmonary embolism. Normal peripheral oxygen saturation and normal ECG, make the diagnosis of pulmonary embolism less likely. To exclude pericardial effusion, an urgent transthoracic echocardiogram is needed.
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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 50 yr. old male presented with episodes of collapse during the last month. Each episode persisted for about 2-3 minutes. They were self-limiting and associated with twitching of the limbs. There was no associated tonic-clonic movements, tongue biting, urinary or faecal incontinence. On examination he had reversed splitting of S2 and an ejection systolic murmur at the right sternal border. His electrocardiogram (ECG) showed left ventricular hypertrophy with strain pattern. CXR showed an area of calcification over the cardiac silhouette. Which of the following is the most probable diagnosis of this patient?
Your Answer: Aortic stenosis
Explanation:The classic triad of symptoms in patients with aortic stenosis is chest pain, heart failure and syncope. Pulsus parvus et tardus, pulsus alternans, hyperdynamic left ventricle, reversed splitting of the S2, prominent S4 and systolic murmur are some of the common findings of aortic stenosis. A calcified aortic valve is found in almost all adults with hemodynamically significant aortic stenosis.
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This question is part of the following fields:
- Cardiology
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Question 18
Correct
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A 18 yr. old male was screened for hypertrophic cardiomyopathy (HOCM) as his brother had the same condition. What is the echocardiographic finding that is related to the highest risk of sudden cardiac death?
Your Answer: Significant thickening of the interventricular septum
Explanation:There are five prognostic factors which indicate poor prognosis in HOCM:
-family history of HOCM-related sudden cardiac death
-unexplained recent syncope
-large left ventricular wall thickness (MLVWT ≥ 30 mm)
-multiple bursts of nsVT on ambulatory electrocardiography
-hypotensive or attenuated blood pressure response to exercise -
This question is part of the following fields:
- Cardiology
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Question 19
Correct
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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: 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 20
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: Left ventricular aneurysm
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 21
Correct
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A 60 yr. old patient with hypertension attended his regular clinic. His compliance was poor. His blood pressure was 180/100 mmHg. His pulse rate was 85 bpm which was irregularly irregular. On examination there was bibasal crepitation. No murmurs were heard. What is the most likely cause for these findings?
Your Answer: Left ventricular hypertrophy
Explanation:Left ventricular hypertrophy due to long standing hypertension is the most probable cause. The irregularly irregular pulse was suggestive of atrial fibrillation, which is due to diastolic dysfunction. Poor ventricular filling causes pulmonary congestion which manifests as bibasal crepitations.
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This question is part of the following fields:
- Cardiology
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Question 22
Incorrect
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A 70 yr. old male patient presented with increased difficulty in breathing during the last 4 months. He was diagnosed with mitral stenosis. On examination his BP was 120/80 mmHg and pulse rate was 68 bpm. There were bibasal crepitations on auscultation. He was on bisoprolol, frusemide and ISDN. From the given answers, what is the most likely indication of worsening of his mitral stenosis?
Your Answer: Periods of complete heart block
Correct Answer: Haemoptysis
Explanation:Haemoptysis is a symptom which indicates the worsening of mitral stenosis. It occurs due to the rupture of pulmonary veins or the capillary system due to pulmonary venous hypertension. Elevated serum creatinine is seen in worsening aortic stenosis. Worsening of tricuspid regurgitation causes ascites and a pulsatile liver.
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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 60 yr. old female presented after an acute overdose of amiodarone. Her blood pressure was 110/70 mmHg and pulse rate was 35 bpm. She was given 500mcg of atropine but there was no response. Which of the following is the most appropriate next step?
Your Answer: Adrenaline
Correct Answer: Isoprenaline
Explanation:Permanent pacing is not indicated as the bradycardia is reversible. Temporary pacing is the definite treatment. Isoprenaline can be used until temporary pacing is available.
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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 50 yr. old male patient presented with acute chest pain and a non ST elevation myocardial infarction (NSTEMI) was diagnosed. He was threated with aspirin 300mg and 2 puffs of glyceral trin (GTN) spray. According to NICE guidelines, which of the following categories of patients should receive clopidogrel?
Your Answer: Patients who have a history of hypertension, ischaemic heart disease or diabetes mellitus
Correct Answer: All patients
Explanation:According to NICE guidelines (2013) all people who have had an acute MI treatment should be offered with ACE inhibitor, dual antiplatelet therapy (aspirin plus a second antiplatelet agent), a beta-blocker and a statin.
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This question is part of the following fields:
- Cardiology
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Question 25
Correct
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A 30 yr. old male patient presented with palpitations that occur randomly at rest. There have however been episodes of fast palpitations and dizziness on exertion. On examination there was a systolic murmur at the apex as well as a prominent apex beat and the chest was clear. Which of the following is LEAST likely to suggest a diagnosis of hypertrophic cardiomyopathy?
Your Answer: A history of hypertension for 10 years
Explanation:Hypertrophic cardiomyopathy is an autosomal dominant condition. Patients present with sudden cardiac death, dyspnoea, syncope and presyncope, angina, palpitations, orthopnoea and paroxysmal nocturnal dyspnoea, Congestive heart failure and dizziness. Physical findings include double or triple apical impulse, prominent a wave in the JVP, an ejection systolic crescendo-decrescendo murmur and a holosystolic murmur at the apex and axilla of mitral regurgitation.
ECG shows ST-T wave abnormalities and LVH, axis deviation (right or left), conduction abnormalities (P-R prolongation, bundle-branch block), sinus bradycardia with ectopic atrial rhythm, atrial enlargement, abnormal and prominent Q wave in the anterior precordial and lateral limb leads.
2D echocardiography shows abnormal systolic anterior leaflet motion of the mitral valve, LVH, 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, partial systolic closure of the aortic valve in midsystole -
This question is part of the following fields:
- Cardiology
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Question 26
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: Amiodarone 200mg
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 27
Correct
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A 60 yr. old man presented with difficulty in breathing. On examination he was severely dyspnoeic and tachycardic. What is the clinical sign that would favour the diagnosis of cardiac tamponade over constrictive pericarditis?
Your Answer: Pulsus paradoxus
Explanation:Pulsus paradoxus is defined as the exaggerated fall in systolic blood pressure during inspiration by greater than 10 mmHg. Cardiac tamponade is the classic cause of pulsus paradoxus. Kussmaul’s sign (a rise in the jugular venous pressure on inspiration) is mostly seen in constrictive pericarditis. Hypotension, muffled heart sounds and raised JVP can be seen in both conditions.
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This question is part of the following fields:
- Cardiology
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Question 28
Correct
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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: 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 29
Incorrect
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A 25 yr. old previously well female, in her 10th week of pregnancy presented with a left sided painful calf swelling. An ultrasound scan revealed deep venous thrombosis (DVT) of her left leg. Which of the following is the most appropriate management of this patient?
Your Answer: Tubigrip stocking; avoid anticoagulation
Correct Answer: Initiate and then continue treatment with heparin until delivery
Explanation:Warfarin is contraindicated during pregnancy due to its teratogenic effects. She should be given heparin throughout her pregnancy. It can be converted to warfarin if necessary after the delivery.
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This question is part of the following fields:
- Cardiology
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Question 30
Incorrect
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A 65 yr. old male patient admitted with myocardial infarction received thrombolysis, which lead to full resolution of the ST elevations on his ECG. He was on aspirin, clopidogrel, atorvastatin and enalapril. The next day he complained of pain in his legs and there was a diffuse petechial rash over his lower legs, especially in the feet. All his peripheral pulses were palpable. His FBC revealed neutrophilia with eosinophilia. His IgE antibodies were 3 kU/L (<2). What is the most likely reason for this presentation?
Your Answer:
Correct Answer: Cholesterol emboli
Explanation:He has a consequence of atherosclerotic disease (MI). The most probable diagnosis is cutaneous cholesterol emboli as it is more common after anticoagulation or thrombolytics, the skin involvement, eosinophilia and raised IgE. It is more common above 60 yrs. of age.
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This question is part of the following fields:
- Cardiology
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SESSION STATS - PERFORMANCE PER SPECIALTY
