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  • Question 1 - A 39-year-old male arrives at the emergency department complaining of palpitations and is...

    Incorrect

    • A 39-year-old male arrives at the emergency department complaining of palpitations and is diagnosed with monomorphic ventricular tachycardia. What electrolyte is responsible for maintaining the resting potential of ventricular myocytes?

      Your Answer: Calcium

      Correct Answer: Potassium

      Explanation:

      The resting potential of cardiac myocytes is maintained by potassium, while depolarization is initiated by a sudden influx of sodium ions and repolarization is caused by the outflow of potassium. The extended duration of a cardiac action potential, in contrast to skeletal muscle, is due to a gradual influx of calcium.

      Understanding the Cardiac Action Potential and Conduction Velocity

      The cardiac action potential is a series of electrical events that occur in the heart during each heartbeat. It is responsible for the contraction of the heart muscle and the pumping of blood throughout the body. The action potential is divided into five phases, each with a specific mechanism. The first phase is rapid depolarization, which is caused by the influx of sodium ions. The second phase is early repolarization, which is caused by the efflux of potassium ions. The third phase is the plateau phase, which is caused by the slow influx of calcium ions. The fourth phase is final repolarization, which is caused by the efflux of potassium ions. The final phase is the restoration of ionic concentrations, which is achieved by the Na+/K+ ATPase pump.

      Conduction velocity is the speed at which the electrical signal travels through the heart. The speed varies depending on the location of the signal. Atrial conduction spreads along ordinary atrial myocardial fibers at a speed of 1 m/sec. AV node conduction is much slower, at 0.05 m/sec. Ventricular conduction is the fastest in the heart, achieved by the large diameter of the Purkinje fibers, which can achieve velocities of 2-4 m/sec. This allows for a rapid and coordinated contraction of the ventricles, which is essential for the proper functioning of the heart. Understanding the cardiac action potential and conduction velocity is crucial for diagnosing and treating heart conditions.

    • This question is part of the following fields:

      • Cardiovascular System
      7
      Seconds
  • Question 2 - A patient in his 60s with dilated cardiomyopathy visits his primary care physician...

    Incorrect

    • A patient in his 60s with dilated cardiomyopathy visits his primary care physician complaining of heart failure symptoms. What is the reason behind his heart condition causing heart failure?

      Your Answer: Increased stretch detected in the atrium leads to tachycardia

      Correct Answer: Ventricular dilatation increases afterload due to Laplace's law

      Explanation:

      Laplace’s law states that the pressure in a lumen is equal to the wall tension divided by the lumen radius. Heart failure occurs when the heart is unable to meet the body’s demands for cardiac output. While an increased end diastolic volume can initially increase cardiac output, if myocytes become too stretched, cardiac output will decrease. Insufficient blood supply to the myocardium can also cause heart failure, but this is not related to dilated cardiomyopathy. The Bainbridge reflex and baroreceptor reflex are the main controllers of heart rate, with the former responding to increased stretch in the atrium. Ventricular dilatation does not directly cause an increase in aortic pressure. Laplace’s law shows that as the ventricle dilates, tension must increase to maintain pressure, but at a certain point, myocytes will no longer be able to exert enough force, leading to heart failure. Additionally, as the ventricle dilates, afterload increases, which is the force the heart must contract against.

      The heart has four chambers and generates pressures of 0-25 mmHg on the right side and 0-120 mmHg on the left. The cardiac output is the product of heart rate and stroke volume, typically 5-6L per minute. The cardiac impulse is generated in the sino atrial node and conveyed to the ventricles via the atrioventricular node. Parasympathetic and sympathetic fibers project to the heart via the vagus and release acetylcholine and noradrenaline, respectively. The cardiac cycle includes mid diastole, late diastole, early systole, late systole, and early diastole. Preload is the end diastolic volume and afterload is the aortic pressure. Laplace’s law explains the rise in ventricular pressure during the ejection phase and why a dilated diseased heart will have impaired systolic function. Starling’s law states that an increase in end-diastolic volume will produce a larger stroke volume up to a point beyond which stroke volume will fall. Baroreceptor reflexes and atrial stretch receptors are involved in regulating cardiac output.

    • This question is part of the following fields:

      • Cardiovascular System
      34.8
      Seconds
  • Question 3 - A 75-year-old man presents to the emergency department with sudden onset chest pain...

    Correct

    • A 75-year-old man presents to the emergency department with sudden onset chest pain that started 3 hours ago and is radiating to his left shoulder. He reports feeling a heavy pressure over his sternum. The patient has a 40-year history of smoking one pack of cigarettes per day and was diagnosed with hyperlipidaemia 25 years ago. An initial ECG reveals ST elevation in V3 and V4. Despite resuscitative efforts, the patient passes away. Upon autopsy, a section of the left anterior descending artery stained with haematoxylin and eosin shows atheroma formation.

      What is the final step in the pathogenesis of the autopsy finding in this case?

      Your Answer: Smooth muscle migration from tunica media

      Explanation:

      An elderly patient with typical anginal pain is likely suffering from ischaemic heart disease, which is commonly caused by atherosclerosis. This patient has risk factors for atherosclerosis, including smoking and hyperlipidaemia.

      Atherosclerosis begins with thickening of the tunica intima, which is mainly composed of proteoglycan-rich extracellular matrix and acellular lipid pools. Fatty streaks, which are minimal lipid depositions on the luminal surface, can be seen in normal individuals and are not necessarily a part of the atheroma. They can begin as early as in the twenties.

      As the disease progresses, fibroatheroma develops, characterized by infiltration of macrophages and T-lymphocytes, with the formation of a well-demarcated lipid-rich necrotic core. Foam cells appear early in the disease process and play a major role in atheroma formation.

      Further progression leads to thin cap fibroatheroma, where the necrotic core becomes bigger and the fibrous cap thins out. Throughout the process, there is a progressive increase in the number of inflammatory cells. Finally, smooth muscle cells from the tunica media proliferate and migrate into the tunica intima, completing the formation of the atheroma.

      Understanding Atherosclerosis and its Complications

      Atherosclerosis is a complex process that occurs over several years. It begins with endothelial dysfunction triggered by factors such as smoking, hypertension, and hyperglycemia. This leads to changes in the endothelium, including inflammation, oxidation, proliferation, and reduced nitric oxide bioavailability. As a result, low-density lipoprotein (LDL) particles infiltrate the subendothelial space, and monocytes migrate from the blood and differentiate into macrophages. These macrophages that phagocytose oxidized LDL, slowly turning into large ‘foam cells’. Smooth muscle proliferation and migration from the tunica media into the intima result in the formation of a fibrous capsule covering the fatty plaque.

      Once a plaque has formed, it can cause several complications. For example, it can form a physical blockage in the lumen of the coronary artery, leading to reduced blood flow and oxygen to the myocardium, resulting in angina. Alternatively, the plaque may rupture, potentially causing a complete occlusion of the coronary artery and resulting in a myocardial infarction. It is essential to understand the process of atherosclerosis and its complications to prevent and manage cardiovascular diseases effectively.

    • This question is part of the following fields:

      • Cardiovascular System
      40.3
      Seconds
  • Question 4 - A middle-aged man is informed of his hypertension during routine check-ups. The physician...

    Correct

    • A middle-aged man is informed of his hypertension during routine check-ups. The physician clarifies that his age increases the likelihood of a secondary cause for his hypertension. What is the primary cause of secondary hypertension?

      Your Answer: Renal disease

      Explanation:

      Secondary hypertension is primarily caused by renal disease, while other endocrine diseases like hyperaldosteronism, phaeochromocytoma, and acromegaly are less common culprits. Malignancy and pregnancy typically do not lead to hypertension, although pregnancy can result in pre-eclampsia, which is characterized by high blood pressure. Certain medications, such as NSAIDs and glucocorticoids, can also induce hypertension.

      Secondary Causes of Hypertension

      Hypertension, or high blood pressure, can be caused by various factors. While primary hypertension has no identifiable cause, secondary hypertension is caused by an underlying medical condition. The most common cause of secondary hypertension is primary hyperaldosteronism, which accounts for 5-10% of cases. Other causes include renal diseases such as glomerulonephritis, pyelonephritis, adult polycystic kidney disease, and renal artery stenosis. Endocrine disorders like phaeochromocytoma, Cushing’s syndrome, Liddle’s syndrome, congenital adrenal hyperplasia, and acromegaly can also result in increased blood pressure. Certain medications like steroids, monoamine oxidase inhibitors, the combined oral contraceptive pill, NSAIDs, and leflunomide can also cause hypertension. Pregnancy and coarctation of the aorta are other possible causes. Identifying and treating the underlying condition is crucial in managing secondary hypertension.

    • This question is part of the following fields:

      • Cardiovascular System
      30.7
      Seconds
  • Question 5 - A 30-year-old male patient complains of shortness of breath, weight loss, and night...

    Correct

    • A 30-year-old male patient complains of shortness of breath, weight loss, and night sweats for the past six weeks. Despite being generally healthy, he has been experiencing these symptoms. During the examination, the patient's fingers show clubbing, and his temperature is 37.8°C. His pulse is 88 bpm, and his blood pressure is 128/80 mmHg. A pansystolic murmur is audible upon auscultation of the heart. What is the probable diagnosis?

      Your Answer: Infective endocarditis

      Explanation:

      Possible Diagnosis for a Young Man with Night Sweats and Clubbing of Fingers

      This young man has been experiencing night sweats and has clubbing of the fingers, which suggests a long history of illness. These symptoms, along with the presence of a murmur, point towards a possible diagnosis of infective endocarditis. Other symptoms that may be present in such cases include splinter haemorrhages in the nails, Roth spots in the eyes, and Osler’s nodes and Janeway lesions in the palms and fingers of the hands.

      In summary, the combination of night sweats, clubbing of fingers, and a murmur in a young man may indicate infective endocarditis. It is important to look for other symptoms such as splinter haemorrhages, Roth spots, Osler’s nodes, and Janeway lesions to confirm the diagnosis.

    • This question is part of the following fields:

      • Cardiovascular System
      6.9
      Seconds
  • Question 6 - As a medical student observing a parathyroidectomy in the short-stay surgical theatre, you...

    Correct

    • As a medical student observing a parathyroidectomy in the short-stay surgical theatre, you witness the ligation of blood vessels supplying the parathyroid glands. The ENT consultant requests you to identify the arteries responsible for supplying oxygenated blood to the parathyroid gland. Can you correctly name these arteries?

      Your Answer: Superior and inferior thyroid arteries

      Explanation:

      The superior and inferior thyroid arteries provide oxygenated blood supply to the parathyroid glands. The existence of inferior parathyroid arteries and superior parathyroid arteries is not supported by anatomical evidence. While a middle thyroid artery may exist in some individuals, it is a rare variation that is not relevant to the question at hand.

      Anatomy and Development of the Parathyroid Glands

      The parathyroid glands are four small glands located posterior to the thyroid gland within the pretracheal fascia. They develop from the third and fourth pharyngeal pouches, with those derived from the fourth pouch located more superiorly and associated with the thyroid gland, while those from the third pouch lie more inferiorly and may become associated with the thymus.

      The blood supply to the parathyroid glands is derived from the inferior and superior thyroid arteries, with a rich anastomosis between the two vessels. Venous drainage is into the thyroid veins. The parathyroid glands are surrounded by various structures, with the common carotid laterally, the recurrent laryngeal nerve and trachea medially, and the thyroid anteriorly. Understanding the anatomy and development of the parathyroid glands is important for their proper identification and preservation during surgical procedures.

    • This question is part of the following fields:

      • Cardiovascular System
      25.7
      Seconds
  • Question 7 - A 70-year-old man presents to the cardiology clinic with complaints of worsening shortness...

    Incorrect

    • A 70-year-old man presents to the cardiology clinic with complaints of worsening shortness of breath and leg swelling over the past 3 months. Upon examination, there is pitting edema to his thighs bilaterally with palpable sacral edema. Bibasal crackles are heard upon auscultation. What medication can be prescribed to improve the prognosis of the underlying condition?

      Your Answer: Furosemide

      Correct Answer: Ramipril

      Explanation:

      Ramipril is the correct medication for this patient with likely chronic heart failure. It is one of the few drugs that has been shown to improve the overall prognosis of heart failure, along with beta-blockers and aldosterone antagonists. Aspirin, digoxin, and furosemide are commonly used in the management of heart failure but do not offer prognostic benefit.

      Chronic heart failure can be managed through drug treatment, according to updated guidelines issued by NICE in 2018. While loop diuretics are useful in managing fluid overload, they do not reduce mortality in the long term. The first-line treatment for all patients is a combination of an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Aldosterone antagonists are recommended as second-line treatment, but potassium levels should be monitored as both ACE inhibitors and aldosterone antagonists can cause hyperkalaemia. Third-line treatment should be initiated by a specialist and may include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, and cardiac resynchronisation therapy. Other treatments include annual influenzae and one-off pneumococcal vaccines. Those with asplenia, splenic dysfunction, or chronic kidney disease may require a booster every 5 years.

    • This question is part of the following fields:

      • Cardiovascular System
      7.5
      Seconds
  • Question 8 - With respect to the basilic vein, which statement is not true? ...

    Correct

    • With respect to the basilic vein, which statement is not true?

      Your Answer: Its deep anatomical location makes it unsuitable for use as an arteriovenous access site in fistula surgery

      Explanation:

      A basilic vein transposition is a surgical procedure that utilizes it during arteriovenous fistula surgery.

      The Basilic Vein: A Major Pathway of Venous Drainage for the Arm and Hand

      The basilic vein is one of the two main pathways of venous drainage for the arm and hand, alongside the cephalic vein. It begins on the medial side of the dorsal venous network of the hand and travels up the forearm and arm. Most of its course is superficial, but it passes deep under the muscles midway up the humerus. Near the region anterior to the cubital fossa, the basilic vein joins the cephalic vein.

      At the lower border of the teres major muscle, the anterior and posterior circumflex humeral veins feed into the basilic vein. It is often joined by the medial brachial vein before draining into the axillary vein. The basilic vein is continuous with the palmar venous arch distally and the axillary vein proximally. Understanding the path and function of the basilic vein is important for medical professionals in diagnosing and treating conditions related to venous drainage in the arm and hand.

    • This question is part of the following fields:

      • Cardiovascular System
      21.6
      Seconds
  • Question 9 - A 36-year-old male comes to his GP complaining of chest pain that has...

    Correct

    • A 36-year-old male comes to his GP complaining of chest pain that has been present for a week. The pain worsens when he breathes in and is relieved when he sits forward. He also has a non-productive cough. He recently had a viral infection. An ECG was performed and showed global saddle-shaped ST elevation.

      Your Answer: Acute pericarditis

      Explanation:

      Chest pain that is relieved by sitting or leaning forward is often a symptom of acute pericarditis. This condition is commonly caused by a viral infection and may also present with flu-like symptoms, non-productive cough, and dyspnea. ECG changes may show a saddle-shaped ST elevation.

      Cardiac tamponade, on the other hand, is characterized by Beck’s triad, which includes hypotension, raised JVP, and muffled heart sounds. Dyspnea and tachycardia may also be present.

      A myocardial infarction is unlikely if the chest pain has been present for a week, as it typically presents more acutely and with constant chest pain regardless of body positioning. ECG changes would also occur in specific territories rather than globally.

      A pneumothorax presents with sudden onset dyspnea, pleuritic chest pain, tachypnea, and sweating. No ECG changes would be observed.

      A pulmonary embolism typically presents with acute onset tachypnea, fever, tachycardia, and crackles. Signs of deep vein thrombosis may also be present.

      Acute Pericarditis: Causes, Features, Investigations, and Management

      Acute pericarditis is a possible diagnosis for patients presenting with chest pain. The condition is characterized by chest pain, which may be pleuritic and relieved by sitting forwards. Other symptoms include non-productive cough, dyspnoea, and flu-like symptoms. Tachypnoea and tachycardia may also be present, along with a pericardial rub.

      The causes of acute pericarditis include viral infections, tuberculosis, uraemia, trauma, post-myocardial infarction, Dressler’s syndrome, connective tissue disease, hypothyroidism, and malignancy.

      Investigations for acute pericarditis include ECG changes, which are often global/widespread, as opposed to the ‘territories’ seen in ischaemic events. The ECG may show ‘saddle-shaped’ ST elevation and PR depression, which is the most specific ECG marker for pericarditis. All patients with suspected acute pericarditis should have transthoracic echocardiography.

      Management of acute pericarditis involves treating the underlying cause. A combination of NSAIDs and colchicine is now generally used as first-line treatment for patients with acute idiopathic or viral pericarditis.

      In summary, acute pericarditis is a possible diagnosis for patients presenting with chest pain. The condition is characterized by chest pain, which may be pleuritic and relieved by sitting forwards, along with other symptoms. The causes of acute pericarditis are varied, and investigations include ECG changes and transthoracic echocardiography. Management involves treating the underlying cause and using a combination of NSAIDs and colchicine as first-line treatment.

    • This question is part of the following fields:

      • Cardiovascular System
      25.3
      Seconds
  • Question 10 - A 67-year-old male arrives at the emergency department with an abrupt onset of...

    Incorrect

    • A 67-year-old male arrives at the emergency department with an abrupt onset of intense chest pain that he describes as tearing through his body. He is promptly diagnosed with a Stanford Type A aortic dissection and immediately undergoes surgical repair. What embryonic structure is responsible for the region where the dissection occurred?

      Your Answer: Ductus arteriosus

      Correct Answer: Truncus arteriosus

      Explanation:

      The truncus arteriosus is responsible for giving rise to both the ascending aorta and the pulmonary trunk during embryonic development.

      When a Stanford Type A aortic dissection occurs, it typically affects the ascending aorta, which originates from the truncus arteriosus.

      During fetal development, the ductus arteriosus allows blood to bypass the pulmonary circuit by shunting it from the pulmonary arteries back into the aortic arch. In adults, the remnant of this structure is known as the ligamentum arteriosum, which serves as an anchor for the aortic arch.

      The bulbus cordis plays a role in the formation of the ventricles, while the common cardinal vein ultimately becomes the superior vena cava.

      During cardiovascular embryology, the heart undergoes significant development and differentiation. At around 14 days gestation, the heart consists of primitive structures such as the truncus arteriosus, bulbus cordis, primitive atria, and primitive ventricle. These structures give rise to various parts of the heart, including the ascending aorta and pulmonary trunk, right ventricle, left and right atria, and majority of the left ventricle. The division of the truncus arteriosus is triggered by neural crest cell migration from the pharyngeal arches, and any issues with this migration can lead to congenital heart defects such as transposition of the great arteries or tetralogy of Fallot. Other structures derived from the primitive heart include the coronary sinus, superior vena cava, fossa ovalis, and various ligaments such as the ligamentum arteriosum and ligamentum venosum. The allantois gives rise to the urachus, while the umbilical artery becomes the medial umbilical ligaments and the umbilical vein becomes the ligamentum teres hepatis inside the falciform ligament. Overall, cardiovascular embryology is a complex process that involves the differentiation and development of various structures that ultimately form the mature heart.

    • This question is part of the following fields:

      • Cardiovascular System
      8.7
      Seconds
  • Question 11 - Which of the following events is commonly observed in the arterioles of individuals...

    Correct

    • Which of the following events is commonly observed in the arterioles of individuals with malignant hypertension?

      Your Answer: Fibrinoid necrosis

      Explanation:

      Arterioles of patients with malignant hypertension exhibit fibrinoid necrosis.

      Understanding Cell Death: Necrosis and Apoptosis

      Cell death can occur through two mechanisms: necrosis and apoptosis. Necrosis is characterized by a failure in bioenergetics, which leads to tissue hypoxia and the inability to generate ATP. This results in the loss of cellular membrane integrity, energy-dependent transport mechanisms, and ionic instability, leading to cellular lysis and the release of intracellular contents that may stimulate an inflammatory response. Different types of necrosis exist, including coagulative, colliquative, caseous, gangrene, fibrinoid, and fat necrosis, with the predominant pattern depending on the tissue type and underlying cause.

      On the other hand, apoptosis, also known as programmed cell death, is an energy-dependent process that involves the activation of caspases triggered by intracellular signaling mechanisms. This results in DNA fragmentation, mitochondrial dysfunction, and nuclear and cellular shrinkage, leading to the formation of apoptotic bodies. Unlike necrosis, phagocytosis of the cell does not occur, and the cell degenerates into apoptotic bodies.

      Understanding the mechanisms of cell death is crucial in various fields, including medicine, biology, and pathology. By identifying the type of cell death, clinicians and researchers can better understand the underlying causes and develop appropriate interventions.

    • This question is part of the following fields:

      • Cardiovascular System
      17.7
      Seconds
  • Question 12 - Following a minor heart attack, how does atorvastatin work to reduce the risk...

    Incorrect

    • Following a minor heart attack, how does atorvastatin work to reduce the risk of a subsequent MI in a 65-year-old patient?

      Your Answer: Decreases LDLs in the blood by inhibiting HMG-CoA reductase in the kidney

      Correct Answer: Decreases LDLs in the blood by inhibiting HMG-CoA reductase in the liver

      Explanation:

      The primary goal of statins is to lower cholesterol levels in the bloodstream, which in turn reduces the risk of cardiovascular events. This is achieved by inhibiting HMG-CoA reductase in the liver, which prevents the synthesis of mevalonate, a precursor to LDLs. As a result, statins decrease the amount of cholesterol being transported to body tissues by LDLs. However, statins do not affect the levels of HDLs, which transport cholesterol from body tissues back to the liver.

      Statins are drugs that inhibit the action of HMG-CoA reductase, which is the enzyme responsible for cholesterol synthesis in the liver. However, they can cause adverse effects such as myopathy, liver impairment, and an increased risk of intracerebral hemorrhage in patients with a history of stroke. Statins should not be taken during pregnancy or in combination with macrolides. NICE recommends statins for patients with established cardiovascular disease, a 10-year cardiovascular risk of 10% or higher, type 2 diabetes mellitus, or type 1 diabetes mellitus with certain criteria. It is recommended to take statins at night, especially simvastatin, which has a shorter half-life than other statins. NICE recommends atorvastatin 20mg for primary prevention and atorvastatin 80 mg for secondary prevention.

    • This question is part of the following fields:

      • Cardiovascular System
      116.6
      Seconds
  • Question 13 - A 50-year-old UK born patient with end-stage kidney failure arrives at the emergency...

    Correct

    • A 50-year-old UK born patient with end-stage kidney failure arrives at the emergency department complaining of sharp chest pain that subsides when sitting forward. The patient has not undergone dialysis yet. Upon conducting an ECG, it is observed that there is a widespread 'saddle-shaped' ST elevation and PR depression, leading to a diagnosis of pericarditis. What could be the probable cause of this pericarditis?

      Your Answer: Uraemia

      Explanation:

      There is no indication of trauma in patients with advanced renal failure prior to dialysis initiation.

      ECG results do not indicate a recent heart attack.

      The patient’s age decreases the likelihood of malignancy.

      Acute Pericarditis: Causes, Features, Investigations, and Management

      Acute pericarditis is a possible diagnosis for patients presenting with chest pain. The condition is characterized by chest pain, which may be pleuritic and relieved by sitting forwards. Other symptoms include non-productive cough, dyspnoea, and flu-like symptoms. Tachypnoea and tachycardia may also be present, along with a pericardial rub.

      The causes of acute pericarditis include viral infections, tuberculosis, uraemia, trauma, post-myocardial infarction, Dressler’s syndrome, connective tissue disease, hypothyroidism, and malignancy.

      Investigations for acute pericarditis include ECG changes, which are often global/widespread, as opposed to the ‘territories’ seen in ischaemic events. The ECG may show ‘saddle-shaped’ ST elevation and PR depression, which is the most specific ECG marker for pericarditis. All patients with suspected acute pericarditis should have transthoracic echocardiography.

      Management of acute pericarditis involves treating the underlying cause. A combination of NSAIDs and colchicine is now generally used as first-line treatment for patients with acute idiopathic or viral pericarditis.

      In summary, acute pericarditis is a possible diagnosis for patients presenting with chest pain. The condition is characterized by chest pain, which may be pleuritic and relieved by sitting forwards, along with other symptoms. The causes of acute pericarditis are varied, and investigations include ECG changes and transthoracic echocardiography. Management involves treating the underlying cause and using a combination of NSAIDs and colchicine as first-line treatment.

    • This question is part of the following fields:

      • Cardiovascular System
      27.1
      Seconds
  • Question 14 - You are on the ward and notice that an elderly patient lying supine...

    Correct

    • You are on the ward and notice that an elderly patient lying supine in a monitored bed is hypotensive, with a blood pressure of 90/70 mmHg and tachycardic, with a heart rate of 120 beats/minute.

      You adjust the bed to raise the patient's legs by 45 degrees and after 1 minute you measure the blood pressure again. The blood pressure increases to 100/75 and you prescribe a 500mL bag of normal saline to be given IV over 15 minutes.

      What physiological association explains the increase in the elderly patient's blood pressure?

      Your Answer: Venous return is proportional to stroke volume

      Explanation:

      Fluid responsiveness is typically indicated by changes in cardiac output or stroke volume in response to fluid administration. However, the strength of cardiac muscle contraction is influenced by adrenaline and noradrenaline, which enhance cardiac contractility rather than Starling’s law.

      Cardiovascular physiology involves the study of the functions and processes of the heart and blood vessels. One important measure of heart function is the left ventricular ejection fraction, which is calculated by dividing the stroke volume (the amount of blood pumped out of the left ventricle with each heartbeat) by the end diastolic LV volume (the amount of blood in the left ventricle at the end of diastole) and multiplying by 100%. Another key measure is cardiac output, which is the amount of blood pumped by the heart per minute and is calculated by multiplying stroke volume by heart rate.

      Pulse pressure is another important measure of cardiovascular function, which is the difference between systolic pressure (the highest pressure in the arteries during a heartbeat) and diastolic pressure (the lowest pressure in the arteries between heartbeats). Factors that can increase pulse pressure include a less compliant aorta (which can occur with age) and increased stroke volume.

      Finally, systemic vascular resistance is a measure of the resistance to blood flow in the systemic circulation and is calculated by dividing mean arterial pressure (the average pressure in the arteries during a heartbeat) by cardiac output. Understanding these measures of cardiovascular function is important for diagnosing and treating cardiovascular diseases.

    • This question is part of the following fields:

      • Cardiovascular System
      51.4
      Seconds
  • Question 15 - A 50-year-old man has a long femoral line inserted to measure CVP. The...

    Correct

    • A 50-year-old man has a long femoral line inserted to measure CVP. The catheter travels from the common iliac vein to the inferior vena cava. At what vertebral level does this occur?

      Your Answer: L5

      Explanation:

      At the level of L5, the common iliac veins join together to form the inferior vena cava (IVC).

      Anatomy of the Inferior Vena Cava

      The inferior vena cava (IVC) originates from the fifth lumbar vertebrae and is formed by the merging of the left and right common iliac veins. It passes to the right of the midline and receives drainage from paired segmental lumbar veins throughout its length. The right gonadal vein empties directly into the cava, while the left gonadal vein usually empties into the left renal vein. The renal veins and hepatic veins are the next major veins that drain into the IVC. The IVC pierces the central tendon of the diaphragm at the level of T8 and empties into the right atrium of the heart.

      The IVC is related anteriorly to the small bowel, the first and third parts of the duodenum, the head of the pancreas, the liver and bile duct, the right common iliac artery, and the right gonadal artery. Posteriorly, it is related to the right renal artery, the right psoas muscle, the right sympathetic chain, and the coeliac ganglion.

      The IVC is divided into different levels based on the veins that drain into it. At the level of T8, it receives drainage from the hepatic vein and inferior phrenic vein before piercing the diaphragm. At the level of L1, it receives drainage from the suprarenal veins and renal vein. At the level of L2, it receives drainage from the gonadal vein, and at the level of L1-5, it receives drainage from the lumbar veins. Finally, at the level of L5, the common iliac vein merges to form the IVC.

    • This question is part of the following fields:

      • Cardiovascular System
      18.2
      Seconds
  • Question 16 - A 82-year-old male is admitted to the Emergency Room with complaints of severe...

    Correct

    • A 82-year-old male is admitted to the Emergency Room with complaints of severe chest pain that spreads to his left arm and jaw. Upon conducting an Electrocardiography (ECG), it is confirmed that he is suffering from ST-elevation myocardial infarction. He is then transferred for percutaneous coronary intervention but unfortunately, he suffers a cardiac arrest and passes away 12 hours after his initial presentation. What are the probable histological findings that would be observed in his heart?

      Your Answer: Coagulative necrosis, neutrophils, wavy fibres, hypercontraction of myofibrils

      Explanation:

      In the first 24 hours after a myocardial infarction (MI), histology findings show early coagulative necrosis, neutrophils, wavy fibers, and hypercontraction of myofibrils. This stage carries a high risk of ventricular arrhythmia, heart failure, and cardiogenic shock.

      Between 1 and 3 days post-MI, extensive coagulative necrosis and neutrophils are present, which can be associated with fibrinous pericarditis.

      From 3 to 14 days post-MI, macrophages and granulation tissue appear at the margins. This stage carries a high risk of free wall rupture, papillary muscle rupture, and left ventricular pseudoaneurysm.

      Between 2 weeks and several months post-MI, the contracted scar is complete. This stage is associated with Dressler syndrome, heart failure, arrhythmias, and mural thrombus.

      Myocardial infarction (MI) can lead to various complications, which can occur immediately, early, or late after the event. Cardiac arrest is the most common cause of death following MI, usually due to ventricular fibrillation. Cardiogenic shock may occur if a large part of the ventricular myocardium is damaged, and it is difficult to treat. Chronic heart failure may result from ventricular myocardium dysfunction, which can be managed with loop diuretics, ACE-inhibitors, and beta-blockers. Tachyarrhythmias, such as ventricular fibrillation and ventricular tachycardia, are common complications. Bradyarrhythmias, such as atrioventricular block, are more common following inferior MI. Pericarditis is common in the first 48 hours after a transmural MI, while Dressler’s syndrome may occur 2-6 weeks later. Left ventricular aneurysm and free wall rupture, ventricular septal defect, and acute mitral regurgitation are other complications that may require urgent medical attention.

    • This question is part of the following fields:

      • Cardiovascular System
      34.3
      Seconds
  • Question 17 - A 65-year-old man presents to his GP with worsening breathlessness. He reports difficulty...

    Correct

    • A 65-year-old man presents to his GP with worsening breathlessness. He reports difficulty climbing stairs and sleeping, and finds it easier to sleep in his living room chair. He used to manage stairs fine a year ago, but now has to stop twice on the way up.

      When asked about other symptoms, he reports feeling slightly wheezy and occasionally coughing up white sputum. He denies any weight loss. His medical history includes angina, non-diabetic hyperglycaemia, and hypertension. He has smoked 15 cigarettes per day since he was 25 and drinks around 5 pints of lager every Friday and Saturday night.

      On examination, his oxygen saturations are 96%, respiratory rate 16/min at rest, heart rate 78/min, and blood pressure 141/88 mmHg. Bibasal crackles are heard on auscultation of his lungs.

      What is the most likely diagnosis?

      Your Answer: Heart failure

      Explanation:

      Orthopnoea is a distinguishing symptom that can help differentiate between heart failure and COPD in patients. While the symptoms may be non-specific, the presence of orthopnoea, or breathlessness when lying down, is a key indicator of heart failure rather than COPD.

      Although the patient has a significant history of smoking, there are no other signs of lung cancer such as weight loss, persistent cough, or coughing up blood. However, it is recommended to conduct an urgent chest X-ray to rule out any serious underlying conditions.

      In cases of occupational asthma, symptoms tend to worsen when exposed to triggers in the workplace and improve during time off. However, in this patient’s case, the symptoms have been gradually worsening over time.

      Features of Chronic Heart Failure

      Chronic heart failure is a condition that affects the heart’s ability to pump blood effectively. It is characterized by several features that can help in its diagnosis. Dyspnoea, or shortness of breath, is a common symptom of chronic heart failure. Patients may also experience coughing, which can be worse at night and accompanied by pink or frothy sputum. Orthopnoea, or difficulty breathing while lying down, and paroxysmal nocturnal dyspnoea, or sudden shortness of breath at night, are also common symptoms.

      Another feature of chronic heart failure is the presence of a wheeze, known as a cardiac wheeze. Patients may also experience weight loss, known as cardiac cachexia, which occurs in up to 15% of patients. However, this may be hidden by weight gained due to oedema. On examination, bibasal crackles may be heard, and signs of right-sided heart failure, such as a raised JVP, ankle oedema, and hepatomegaly, may be present.

      In summary, chronic heart failure is a condition that can be identified by several features, including dyspnoea, coughing, orthopnoea, paroxysmal nocturnal dyspnoea, wheezing, weight loss, bibasal crackles, and signs of right-sided heart failure. Early recognition and management of these symptoms can help improve outcomes for patients with chronic heart failure.

    • This question is part of the following fields:

      • Cardiovascular System
      26
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  • Question 18 - A 35-year-old man visits his GP complaining of feeling increasingly unwell for the...

    Correct

    • A 35-year-old man visits his GP complaining of feeling increasingly unwell for the past few weeks. He reports experiencing heavy night sweats, fatigue, and shortness of breath. Upon further questioning, he reveals a history of intravenous drug use for many years and has been using methadone exclusively for the last 2 months. During the physical examination, the GP observes splinter haemorrhages. What is the probable causative organism?

      Your Answer: Staphylococcus aureus

      Explanation:

      The patient is exhibiting symptoms that are indicative of infective endocarditis and has a past of using intravenous drugs. Infective endocarditis can be caused by various factors, but in developed countries, S. aureus is the most prevalent cause. This is especially true for individuals who use intravenous drugs, as in this case.

      Aetiology of Infective Endocarditis

      Infective endocarditis is a condition that affects patients with previously normal valves, rheumatic valve disease, prosthetic valves, congenital heart defects, intravenous drug users, and those who have recently undergone piercings. The strongest risk factor for developing infective endocarditis is a previous episode of the condition. The mitral valve is the most commonly affected valve.

      The most common cause of infective endocarditis is Staphylococcus aureus, particularly in acute presentations and intravenous drug users. Historically, Streptococcus viridans was the most common cause, but this is no longer the case except in developing countries. Coagulase-negative Staphylococci such as Staphylococcus epidermidis are commonly found in indwelling lines and are the most common cause of endocarditis in patients following prosthetic valve surgery. Streptococcus bovis is associated with colorectal cancer, with the subtype Streptococcus gallolyticus being most linked to the condition.

      Culture negative causes of infective endocarditis include prior antibiotic therapy, Coxiella burnetii, Bartonella, Brucella, and HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella). It is important to note that systemic lupus erythematosus and malignancy, specifically marantic endocarditis, can also cause non-infective endocarditis.

    • This question is part of the following fields:

      • Cardiovascular System
      19.2
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  • Question 19 - A 5-year-old girl with a history of unrepaired Tetralogy of Fallot has arrived...

    Incorrect

    • A 5-year-old girl with a history of unrepaired Tetralogy of Fallot has arrived at the emergency department with sudden cyanosis and difficulty breathing after crying. Additionally, the patient is administered oxygen, morphine, and propranolol, and is expected to recover well. Surgery to repair the condition is scheduled in the near future.

      What is the term for this cyanotic episode that is commonly associated with Tetralogy of Fallot?

      Your Answer: Neonatal respiratory distress syndrome (NRDS)

      Correct Answer: Tet's spells

      Explanation:

      The correct answer is Tet’s spells, which are episodic hypercyanotic events that can cause loss of consciousness in infants with Tetralogy of Fallot. This condition is characterized by four structural abnormalities in the heart, but Tet’s spells are a specific manifestation of the disease. Acute coronary syndrome and neonatal respiratory distress syndrome are not relevant to this patient’s presentation, while Eisenmenger’s syndrome is a chronic condition that does not fit the acute nature of Tet’s spells.

      Understanding Tetralogy of Fallot

      Tetralogy of Fallot (TOF) is a congenital heart disease that causes cyanosis, or a bluish tint to the skin, due to a lack of oxygen in the blood. It is the most common cause of cyanotic congenital heart disease. TOF is typically diagnosed in infants between 1-2 months old, but may not be detected until they are 6 months old.

      TOF is caused by a malalignment of the aorticopulmonary septum, resulting in four characteristic features: a ventricular septal defect (VSD), right ventricular hypertrophy, pulmonary stenosis, and an overriding aorta. The severity of the right ventricular outflow tract obstruction determines the degree of cyanosis and clinical severity.

      Other symptoms of TOF include episodic hypercyanotic tet spells, which can cause severe cyanosis and loss of consciousness. These spells occur when the right ventricular outflow tract is nearly occluded and are triggered by stress, pain, or fever. A right-to-left shunt may also occur. A chest x-ray may show a boot-shaped heart, and an ECG may show right ventricular hypertrophy.

      Surgical repair is often necessary for TOF, and may be done in two parts. Beta-blockers may also be used to reduce infundibular spasm and help with cyanotic episodes. It is important to diagnose and manage TOF early to prevent complications and improve outcomes.

      Overall, understanding the causes, symptoms, and management of TOF is crucial for healthcare professionals and caregivers to provide the best possible care for infants with this condition.

    • This question is part of the following fields:

      • Cardiovascular System
      9.8
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  • Question 20 - A 50-year-old white male is diagnosed with hypertension during a routine checkup at...

    Correct

    • A 50-year-old white male is diagnosed with hypertension during a routine checkup at his GP clinic. What is the initial choice of antihypertensive medication for white males who are under 55 years of age?

      Your Answer: ACE inhibitor

      Explanation:

      For patients under 55 years of age who are white, ACE inhibitors are the preferred initial medication for hypertension. These drugs have also been shown to improve survival rates after a heart attack and in cases of congestive heart failure.

      However, for black patients or those over 55 years of age, a calcium channel blocker is the recommended first-line treatment. Beta blockers and diuretics are no longer considered the primary medication for hypertension.

      Hypertension is a common medical condition that refers to chronically raised blood pressure. It is a significant risk factor for cardiovascular disease such as stroke and ischaemic heart disease. Normal blood pressure can vary widely according to age, gender, and individual physiology, but hypertension is defined as a clinic reading persistently above 140/90 mmHg or a 24-hour blood pressure average reading above 135/85 mmHg.

      Around 90-95% of patients with hypertension have primary or essential hypertension, which is caused by complex physiological changes that occur as we age. Secondary hypertension may be caused by a variety of endocrine, renal, and other conditions. Hypertension typically does not cause symptoms unless it is very high, but patients may experience headaches, visual disturbance, or seizures.

      Diagnosis of hypertension involves 24-hour blood pressure monitoring or home readings using an automated sphygmomanometer. Patients with hypertension typically have tests to check for renal disease, diabetes mellitus, hyperlipidaemia, and end-organ damage. Management of hypertension involves drug therapy using antihypertensives, modification of other risk factors, and monitoring for complications. Common drugs used to treat hypertension include angiotensin-converting enzyme inhibitors, calcium channel blockers, thiazide type diuretics, and angiotensin II receptor blockers. Drug therapy is decided by well-established NICE guidelines, which advocate a step-wise approach.

    • This question is part of the following fields:

      • Cardiovascular System
      5.7
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  • Question 21 - A 25-year-old man experiences a blunt head trauma and presents with a GCS...

    Correct

    • A 25-year-old man experiences a blunt head trauma and presents with a GCS of 7 upon admission. What is the primary factor influencing cerebral blood flow in this scenario?

      Your Answer: Intracranial pressure

      Explanation:

      Cerebral blood flow can be impacted by both hypoxaemia and acidosis, but in cases of trauma, the likelihood of increased intracranial pressure is much higher, particularly when the Glasgow Coma Scale (GCS) is low. This can have a negative impact on cerebral blood flow.

      Understanding Cerebral Blood Flow and Angiography

      Cerebral blood flow is regulated by the central nervous system, which can adjust its own blood supply. Various factors can affect cerebral pressure, including CNS metabolism, trauma, pressure, and systemic carbon dioxide levels. The most potent mediator is PaCO2, while acidosis and hypoxemia can also increase cerebral blood flow to a lesser degree. In patients with head injuries, increased intracranial pressure can impair blood flow. The Monro-Kelly Doctrine governs intracerebral pressure, which considers the brain as a closed box, and changes in pressure are offset by the loss of cerebrospinal fluid. However, when this is no longer possible, intracranial pressure rises.

      Cerebral angiography is an invasive test that involves injecting contrast media into the carotid artery using a catheter. Radiographs are taken as the dye works its way through the cerebral circulation. This test can be used to identify bleeding aneurysms, vasospasm, and arteriovenous malformations, as well as differentiate embolism from large artery thrombosis. Understanding cerebral blood flow and angiography is crucial in diagnosing and treating various neurological conditions.

    • This question is part of the following fields:

      • Cardiovascular System
      17.8
      Seconds
  • Question 22 - A 67-year-old man comes to the emergency department with concerns of pain in...

    Correct

    • A 67-year-old man comes to the emergency department with concerns of pain in his right foot. Upon examination, you observe a slow capillary refill and a cold right foot. The patient is unable to move his toes, and the foot is tender. You can detect a pulse behind his medial malleolus and in his popliteal fossa, but there are no pulses in his foot. Which artery is likely affected in this patient's condition?

      Your Answer: Anterior tibial

      Explanation:

      The dorsalis pedis artery in the foot is a continuation of the anterior tibial artery. However, in a patient presenting with acute limb ischemia and an absent dorsalis pedis artery pulse, it is likely that the anterior tibial artery is occluded. This can cause severe ischemia, as evidenced by a cold and tender foot with decreased motor function. The presence of a palpable popliteal pulse suggests that the femoral artery is not occluded. Occlusion of the fibular artery would not typically result in an absent dorsalis pedis pulse, while occlusion of the posterior tibial artery would result in no pulse present posterior to the medial malleolus, where this artery runs.

      The anterior tibial artery starts opposite the lower border of the popliteus muscle and ends in front of the ankle, where it continues as the dorsalis pedis artery. As it descends, it runs along the interosseous membrane, the distal part of the tibia, and the front of the ankle joint. The artery passes between the tendons of the extensor digitorum and extensor hallucis longus muscles as it approaches the ankle. The deep peroneal nerve is closely related to the artery, lying anterior to the middle third of the vessel and lateral to it in the lower third.

    • This question is part of the following fields:

      • Cardiovascular System
      109
      Seconds
  • Question 23 - A 67-year-old woman visits her GP for a routine hypertension check-up. She has...

    Correct

    • A 67-year-old woman visits her GP for a routine hypertension check-up. She has been on amlodipine for a year and her blood pressure is under control, but she frequently experiences ankle swelling. The swelling is more pronounced towards the end of the day since she started taking amlodipine. The GP decides to switch her medication to a diuretic. Which diuretic targets the sodium-chloride transporter in the distal tubule?

      Your Answer: Bendroflumethiazide (thiazide diuretic)

      Explanation:

      Thiazide diuretics are medications that work by blocking the thiazide-sensitive Na+-Cl− symporter, which inhibits sodium reabsorption at the beginning of the distal convoluted tubule (DCT). This results in the loss of potassium as more sodium reaches the collecting ducts. While thiazide diuretics are useful in treating mild heart failure, loop diuretics are more effective in reducing overload. Bendroflumethiazide was previously used to manage hypertension, but recent NICE guidelines recommend other thiazide-like diuretics such as indapamide and chlorthalidone.

      Common side effects of thiazide diuretics include dehydration, postural hypotension, and electrolyte imbalances such as hyponatremia, hypokalemia, and hypercalcemia. Other potential adverse effects include gout, impaired glucose tolerance, and impotence. Rare side effects may include thrombocytopenia, agranulocytosis, photosensitivity rash, and pancreatitis.

      It is worth noting that while thiazide diuretics may cause hypercalcemia, they can also reduce the incidence of renal stones by decreasing urinary calcium excretion. According to current NICE guidelines, the management of hypertension involves the use of thiazide-like diuretics, along with other medications and lifestyle changes, to achieve optimal blood pressure control and reduce the risk of cardiovascular disease.

    • This question is part of the following fields:

      • Cardiovascular System
      39.4
      Seconds
  • Question 24 - A 30-year-old male arrives at the emergency department complaining of sudden dizziness and...

    Incorrect

    • A 30-year-old male arrives at the emergency department complaining of sudden dizziness and palpitations. His medical history reveals that he had infectious diarrhea a week ago and was prescribed a 10-day course of erythromycin. Upon examination, an ECG confirms fast atrial fibrillation. The physician decides to use amiodarone to convert the patient into sinus rhythm. What is one potential risk associated with the use of amiodarone in this patient?

      Your Answer: Yellow appearance of skin

      Correct Answer: Ventricular arrhythmias

      Explanation:

      The risk of ventricular arrhythmias is increased when amiodarone and erythromycin are used together due to their ability to prolong the QT interval. Manufacturers advise against using multiple drugs that prolong QT interval to avoid this risk. WPW syndrome is a congenital condition that involves abnormal conductive cardiac tissue and can lead to reentrant tachycardia circuit in association with SVT. Amiodarone can cause a slate-grey appearance of the skin, while drugs like rifampicin can cause orange discoloration of body fluids. COPD is associated with multifocal atrial tachycardia.

      Amiodarone is a medication used to treat various types of abnormal heart rhythms. It works by blocking potassium channels, which prolongs the action potential and helps to regulate the heartbeat. However, it also has other effects, such as blocking sodium channels. Amiodarone has a very long half-life, which means that loading doses are often necessary. It should ideally be given into central veins to avoid thrombophlebitis. Amiodarone can cause proarrhythmic effects due to lengthening of the QT interval and can interact with other drugs commonly used at the same time. Long-term use of amiodarone can lead to various adverse effects, including thyroid dysfunction, corneal deposits, pulmonary fibrosis/pneumonitis, liver fibrosis/hepatitis, peripheral neuropathy, myopathy, photosensitivity, a ‘slate-grey’ appearance, thrombophlebitis, injection site reactions, and bradycardia. Patients taking amiodarone should be monitored regularly with tests such as TFT, LFT, U&E, and CXR.

    • This question is part of the following fields:

      • Cardiovascular System
      28.9
      Seconds
  • Question 25 - A 78-year-old woman has recently been diagnosed with heart failure following 10 months...

    Incorrect

    • A 78-year-old woman has recently been diagnosed with heart failure following 10 months of progressive ankle swelling and shortness of breath. She has been prescribed various medications, provided with lifestyle recommendations, and informed about her prognosis. Due to her new diagnosis, what are the two types of valve dysfunction that she is most susceptible to?

      Your Answer: Aortic stenosis and mitral regurgitation

      Correct Answer: Mitral regurgitation and tricuspid regurgitation

      Explanation:

      Functional mitral and tricuspid regurgitations are the most frequent valve dysfunctions that occur as a result of heart failure. This is due to the fact that the enlarged ventricles prevent the valves from fully closing during diastole.

      Diagnosis of Chronic Heart Failure

      Chronic heart failure is a serious condition that requires prompt diagnosis and management. In 2018, the National Institute for Health and Care Excellence (NICE) updated its guidelines on the diagnosis and management of chronic heart failure. According to the new guidelines, all patients should undergo an N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test as the first-line investigation, regardless of whether they have previously had a myocardial infarction or not.

      Interpreting the NT-proBNP test is crucial in determining the severity of the condition. If the levels are high, specialist assessment, including transthoracic echocardiography, should be arranged within two weeks. If the levels are raised, specialist assessment, including echocardiogram, should be arranged within six weeks.

      BNP is a hormone produced mainly by the left ventricular myocardium in response to strain. Very high levels of BNP are associated with a poor prognosis. The table above shows the different levels of BNP and NTproBNP and their corresponding interpretations.

      It is important to note that certain factors can alter the BNP level. For instance, left ventricular hypertrophy, ischaemia, tachycardia, and right ventricular overload can increase BNP levels, while diuretics, ACE inhibitors, beta-blockers, angiotensin 2 receptor blockers, and aldosterone antagonists can decrease BNP levels. Therefore, it is crucial to consider these factors when interpreting the NT-proBNP test.

    • This question is part of the following fields:

      • Cardiovascular System
      9.4
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  • Question 26 - A 58-year-old man has an out-of-hospital cardiac arrest and is pronounced dead at...

    Correct

    • A 58-year-old man has an out-of-hospital cardiac arrest and is pronounced dead at the scene. A post-mortem examination is carried out to determine the cause of death, which demonstrates 90% stenosis of the left anterior descending artery.

      What is the ultimate stage in the development of this stenosis?

      Your Answer: Smooth muscle proliferation and migration from the tunica media into the intima

      Explanation:

      Understanding Atherosclerosis and its Complications

      Atherosclerosis is a complex process that occurs over several years. It begins with endothelial dysfunction triggered by factors such as smoking, hypertension, and hyperglycemia. This leads to changes in the endothelium, including inflammation, oxidation, proliferation, and reduced nitric oxide bioavailability. As a result, low-density lipoprotein (LDL) particles infiltrate the subendothelial space, and monocytes migrate from the blood and differentiate into macrophages. These macrophages then phagocytose oxidized LDL, slowly turning into large ‘foam cells’. Smooth muscle proliferation and migration from the tunica media into the intima result in the formation of a fibrous capsule covering the fatty plaque.

      Once a plaque has formed, it can cause several complications. For example, it can form a physical blockage in the lumen of the coronary artery, leading to reduced blood flow and oxygen to the myocardium, resulting in angina. Alternatively, the plaque may rupture, potentially causing a complete occlusion of the coronary artery and resulting in a myocardial infarction. It is essential to understand the process of atherosclerosis and its complications to prevent and manage cardiovascular diseases effectively.

    • This question is part of the following fields:

      • Cardiovascular System
      21.2
      Seconds
  • Question 27 - A 63-year-old man arrives at the emergency department complaining of severe chest pain...

    Correct

    • A 63-year-old man arrives at the emergency department complaining of severe chest pain that feels like crushing. He is sweating heavily and feels nauseous. Upon conducting an ECG, you observe ST-segment elevation in multiple chest leads and sinus bradycardia. It is known that myocardial infarction can cause sinus bradycardia. Can you identify the arterial vessel that typically supplies blood to both the sinoatrial (SA) node and the atrioventricular (AV) node?

      Your Answer: Right coronary artery

      Explanation:

      The heart is supplied with blood by the coronary arteries, which branch off from the aorta. The right coronary artery supplies blood to the right side of the heart, while the left coronary artery supplies blood to the left side of the heart.

      Occlusion, or blockage, of the right coronary artery can cause inferior myocardial infarction (MI), which is indicated on an electrocardiogram (ECG) by changes in leads II, III, and aVF. This type of MI is particularly associated with arrhythmias because the right coronary artery usually supplies the sinoatrial (SA) and atrioventricular (AV) nodes.

      The left anterior descending artery (LAD) is one of the two branches of the left coronary artery. It runs along the front of the heart’s interventricular septum to reach the apex of the heart. One or more diagonal branches may arise from the LAD. Occlusion of the LAD can cause anteroseptal MI, which is evident on an ECG with changes in leads V1-V4.

      The right marginal artery branches off from the right coronary artery near the bottom of the heart and continues along the heart’s bottom edge towards the apex.

      The left circumflex artery is the other branch of the left coronary artery. It runs in the coronary sulcus around the base of the heart and gives rise to the left marginal artery. Occlusion of the left circumflex artery is typically associated with lateral MI.

      The left marginal artery arises from the left circumflex artery and runs along the heart’s obtuse margin.

      The walls of each cardiac chamber are made up of the epicardium, myocardium, and endocardium. The heart and roots of the great vessels are related anteriorly to the sternum and the left ribs. The coronary sinus receives blood from the cardiac veins, and the aortic sinus gives rise to the right and left coronary arteries. The left ventricle has a thicker wall and more numerous trabeculae carnae than the right ventricle. The heart is innervated by autonomic nerve fibers from the cardiac plexus, and the parasympathetic supply comes from the vagus nerves. The heart has four valves: the mitral, aortic, pulmonary, and tricuspid valves.

    • This question is part of the following fields:

      • Cardiovascular System
      21.9
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  • Question 28 - A young man in his early twenties collapses during a game of basketball...

    Correct

    • A young man in his early twenties collapses during a game of basketball and is declared dead upon arrival at the hospital. The autopsy shows irregularities in his heart. What is the probable cause of the irregularities?

      Your Answer: Hypertrophic cardiomyopathy

      Explanation:

      The condition that is most commonly associated with sudden death is hypertrophic cardiomyopathy, making the other options less likely.

      Symptoms of acute myocarditis may include chest pain, fever, palpitations, tachycardia, and difficulty breathing.

      Dilated cardiomyopathy may cause right ventricular failure, leading to symptoms such as difficulty breathing, pulmonary edema, and atrial fibrillation.

      Restrictive cardiomyopathy and constrictive pericarditis have similar presentations, with right heart failure symptoms such as elevated JVP, hepatomegaly, edema, and ascites being predominant.

      Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disorder that affects muscle tissue and is inherited in an autosomal dominant manner. It is caused by mutations in genes that encode contractile proteins, with the most common defects involving the β-myosin heavy chain protein or myosin-binding protein C. HOCM is characterized by left ventricle hypertrophy, which leads to decreased compliance and cardiac output, resulting in predominantly diastolic dysfunction. Biopsy findings show myofibrillar hypertrophy with disorganized myocytes and fibrosis. HOCM is often asymptomatic, but exertional dyspnea, angina, syncope, and sudden death can occur. Jerky pulse, systolic murmurs, and double apex beat are also common features. HOCM is associated with Friedreich’s ataxia and Wolff-Parkinson White. ECG findings include left ventricular hypertrophy, non-specific ST segment and T-wave abnormalities, and deep Q waves. Atrial fibrillation may occasionally be seen.

    • This question is part of the following fields:

      • Cardiovascular System
      6.2
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  • Question 29 - Each of the following increases the production of endothelin, except for which one?...

    Correct

    • Each of the following increases the production of endothelin, except for which one?

      Your Answer: Prostacyclin

      Explanation:

      Understanding Endothelin and Its Role in Various Diseases

      Endothelin is a potent vasoconstrictor and bronchoconstrictor that is secreted by the vascular endothelium. Initially, it is produced as a prohormone and later converted to ET-1 by the action of endothelin converting enzyme. Endothelin interacts with a G-protein linked to phospholipase C, leading to calcium release. This interaction is thought to be important in the pathogenesis of many diseases, including primary pulmonary hypertension, cardiac failure, hepatorenal syndrome, and Raynaud’s.

      Endothelin is known to promote the release of angiotensin II, ADH, hypoxia, and mechanical shearing forces. On the other hand, it inhibits the release of nitric oxide and prostacyclin. Raised levels of endothelin are observed in primary pulmonary hypertension, myocardial infarction, heart failure, acute kidney injury, and asthma.

      In recent years, endothelin antagonists have been used to treat primary pulmonary hypertension. Understanding the role of endothelin in various diseases can help in the development of new treatments and therapies.

    • This question is part of the following fields:

      • Cardiovascular System
      31.7
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  • Question 30 - A 50-year-old man with a history of rate-controlled atrial fibrillation (AF) presents with...

    Correct

    • A 50-year-old man with a history of rate-controlled atrial fibrillation (AF) presents with chest pain, palpitations, and dizziness. The patient has a past medical history of a transient ischemic episode and is taking warfarin to prevent further ischemic episodes. He also has a history of gout, low back pain, depression, and polymyalgia rheumatica.

      Upon immediate ECG, the patient is found to have an irregularly irregular rhythm consistent with fast AF. You decide to perform electrical cardioversion and prescribe a course of amiodarone to prevent recurrence.

      What drug interaction should you be cautious of in this patient?

      Your Answer: Warfarin and amiodarone

      Explanation:

      The metabolism of warfarin is reduced by amiodarone, which can increase the risk of bleeding. However, there are no known interactions between amiodarone and naproxen, paracetamol, codeine, or allopurinol. It should be noted that the patient in question is not diabetic and therefore should not be taking metformin.

      Amiodarone is a medication used to treat various types of abnormal heart rhythms. It works by blocking potassium channels, which prolongs the action potential and helps to regulate the heartbeat. However, it also has other effects, such as blocking sodium channels. Amiodarone has a very long half-life, which means that loading doses are often necessary. It should ideally be given into central veins to avoid thrombophlebitis. Amiodarone can cause proarrhythmic effects due to lengthening of the QT interval and can interact with other drugs commonly used at the same time. Long-term use of amiodarone can lead to various adverse effects, including thyroid dysfunction, corneal deposits, pulmonary fibrosis/pneumonitis, liver fibrosis/hepatitis, peripheral neuropathy, myopathy, photosensitivity, a ‘slate-grey’ appearance, thrombophlebitis, injection site reactions, and bradycardia. Patients taking amiodarone should be monitored regularly with tests such as TFT, LFT, U&E, and CXR.

    • This question is part of the following fields:

      • Cardiovascular System
      25.1
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiovascular System (22/30) 73%
Passmed