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Question1of295
A54yearoldmanpresentswithanirregulartachycardiawithaventricularrateofaround120bpm.Heplayedinacricket
matchthepreviousdayandconsumed28unitsofalcoholontheeveningofthematch.Onexaminationhisbloodpressure
is95/50mmHg.
Whatisthemostlikelydiagnosis?
A Atrialflutter
B Paroxysmalatrialfibrillation
C Sicksinussyndrome
D Sinustachycardia
E Ventriculartachycardia
Explanation
TheanswerisParoxysmalatrialfibrillation
Paroxysmalatrialfibrillation(AF)isthecorrectanswer.BothAFandflutterareassociatedwithalcoholicbinges.AF
istypicallyirregular,whereasflutteristypicallyregulariftheAVblockisconsistent.Influtter,theratesaremore
typically150bpm(2:1block)or100bpm(3:1)block.Insomecasestheremaybesubtlefluctuationinthedegreeof
blockcausingsomevariability,butitisrarelyirregularlyirregular.Theotherconditionslistedcanberuledoutas
theyarelessassociatedwithalcoholandaremorelikelytocausearegulartachycardia.
Paroxysmalatrialfibrillation
Episodesoftachycardiainthisconditionmayoccasionallybeprecipitatedbyanexcessintakeofalcoholor
caffeine.
Othercausesmaybe
hypertension
thyroiddisorder
valvularheartdisease
acutemyocardialinfarction(lesscommonthanoftenconsidered)
atrialseptaldefect
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orpreexcitationsyndromessuchasWolffParkinsonWhite.
Atrialflutterisassociatedwithanabsolutelyregularrhythmof150220bpm.
Treatment
Standardtherapyforatrialfibrillationofrecentonsetiselectricalcardioversionunderanticoagulantcover,provided
thattherearenocontraindications.
Patientswhopresentwithin48hoursofonsetcanbeanticoagulatedwithheparinandundergosynchroniseddirect
currentcardioversion(DCCV).
Patientswhopresentafter48hourswillneed46weeksoffullanticoagulation(INRs>2.0ifusingwarfarin)
beforesynchronisedDCCV.Alternatively,earlierDCCVcanbeperformedifatransoesophagealechocardiogram
(TOE)canbedonetoexcludeclotintheleftatrialappendage.
Intravenousflecainidemaybeconsideredforchemicalcardioversionintheabsenceofahistoryofischaemicheart
diseaseamiodaroneisanacceptablealternative.
Longtermprophylaxiswithagentssuchassotalolmayberequired.
Atrialflutter(OptionA)isincorrect.Atrialflutterislessassociatedwithalcoholandismorelikelytocausearegular
tachycardia.
Sicksinussyndrome(OptionC)isincorrect.Sicksinussyndromeislessassociatedwithalcoholandismorelikelyto
causearegulartachycardia.
Sinustachycardia(OptionD)isincorrect.Sinustachycardiaislessassociatedwithalcoholandismorelikelytocausea
regulartachycardia.
Ventriculartachycardia(OptionE)isincorrect.Ventriculartachycardiaislessassociatedwithalcoholandismorelikelyto
causearegulartachycardia.
42012
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Question2of295
Apreviouslyfit25yearoldmanwithahistoryofheavysmokingcomestotheEmergencyDepartmentcomplainingof
breathlessnessandpleuriticpainoccurringsuddenlyinthemiddleofapubteamfootballmatch.Onexamination,a
systolicclickisheardovertheprecordium,andtherearedecreasedbreathsoundsontheleft.
Whatisthepossiblediagnosis?
A Pulmonaryembolism
B Mitralvalveprolapse
C Unstableangina
D Myocardialinfarction
E Pneumothorax
Explanation
TheanswerisPneumothorax
Thisisthemostlikelydiagnosisinayoungfitmanpresentingwithsuddenshortnessofbreath,apleuriticpainand
decreasedbreathsoundsononeside.Primaryspontaneouspneumothoraxisusuallyduetoruptureofapicalpleural
blebsandoccursalmostexclusivelyinsmokers.Thepatientshouldbeassessedforsignsofatensionpneumothorax
(shiftofthetracheatothecontralateralsideandadeterioratingclinicalstatewithhaemodynamiccompromise).
Othernotes:
Suchfeaturesastachycardia,dyspnoeaortachypnoeamaybeabsentinpatientswithevenamoderatetolarge
pulmonaryembolism.
Theremaybeanaccentuatedpulmoniccomponentofthesecondheartsound.
Breathlessnessinthosewithmitralvalveprolapseisinsidiousandprogressesgradually.
Ischaemicpain(heavy,crushingorsqueezing,whichmayradiatetothearms,abdomen,back,lowerjawandneck)
couldrepresentunstableanginapectorisormyocardialinfarction,butthatisunlikelyinthiscasewithhisyoungage
andotherclinicalpresentation.
Pulmonaryembolism(OptionA)isincorrect.Apulmonaryembolismwouldnottypicallybeassociatedwithreduced
breathsounds,andistypicallyassociatedwithapleuralrub.
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Mitralvalveprolapse(OptionB)isincorrect.Pneumothoraces,particularlythoseontheleftsidewiththetrappedair
beingneartheheart,canproduceasystolicclickastheairtrappedbetweenthemediastinalandvisceralpleuraisshifted
bytherhythmicventricularcontractions.Althoughsystolicclickscanbeheardwithmitralvalveprolapse,thisanswer
doesnotfittheclinicalpresentation.
Unstableangina(OptionC)isincorrect.Theclinicalhistoryandphysicalsignsarenotclassicalforunstableangina.
Myocardialinfarction(OptionD)isincorrect.Theclinicalhistoryandphysicalsignsarenotclassicalforamyocardial
infarction.
41972
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Question3of295
A40yearoldmanisreferredbyhisGPforadvicewithregardtoprimarypreventionofcardiovasculardisease.Heisa
smokerwithastrongfamilyhistoryofprematuredeathfromischaemicheartdisease.Followingaperiodoflifestyle
modification,hisfastingcholesterolconcentrationis7.2mmol/litre.Onconsultationofthelocalguidelinesyoufindthat
hisestimated10yearriskofacoronaryheartdiseaseeventis>30%.
Whatwouldyouadvise?
A Cholestyramine
B Dieticianadvice
C Fibrate
D Nicotinicacid
E Statin
Explanation
TheanswerisStatin
Preventionofcardiovasculardisease
TheJointBritishSocieties(JBS)forthePreventionofCardiovascularDiseasehaverecentlyupdatedtheirguidelines
formanaginglipids.
Nonfastingbloodsamplesshouldbetakentomeasuretotalcholesterol(TC)andHDLcholesterol.Inthepast,fast
LDLcwasused,butamorepragmaticapproachofmeasuringnonHDLcisnowbeingproposed(determinedbyTC
minusHDLc=nonHDLc).
AllhighriskpeopleshouldreceiveprofessionallifestylesupporttoreducetotalandLDLc,raiseHDLcandlower
triglyceridestoreducetheirCVDrisk.
Individualsshouldbeofferedinterventionstoaddressallmodifiableriskfactors,including
dietaryadvice
smokingcessationadviceandsupport
moderationofalcoholconsumption
weightreductionwhereappropriate.
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TheriskofpatientsshouldbedeterminedbylevelsrecommendedbyNICE:anumberofdifferentalgorithmsand
riskpredictorsareavailable.NICEcurrentlyrecommendsQRISK2forallprimarypreventionuptotheageof84
years.TheJBShavealsoproducedriskcalculators.
Specificcholesterolloweringdrugtherapyisrecommendedin:
patientswithestablishedCVD
individualsatparticularlyhighriskofCVD:diabetesage>40years,patientswithCKDstages35,orFH
individualswithhigh10yearCVDriskfromthe2014guidelinesthisisconsideredtobethosewith10%
chanceofCVDwithinthenext10years(previouslythiswas30%)
individualswithhighlifetimeCVDriskestimatedfromheartageandotherJBS3calculatormetrics,in
whomlifestylechangesaloneareconsideredinsufficientbythephysicianandpersonconcerned.
StatinsarerecommendedastheyarehighlyeffectiveatreducingCVDeventswithevidenceofbenefittoLDLc
levels<2mmol/litre,whichjustifiesintensivenonHDLclowering.
Statinsarethemosteffectivetherapiesinloweringcholesterollevelsoftheoptionslisted.Thereforeitisthecorrect
answer.
Totalcholesterollevelsof<5andLDLlevels<3shouldbetargetedforallprimarypreventioninsecondary
prevention,<4and<2,respectively.
Statinsaresafe,withtrialevidenceshowingnoeffectsonnoncardiovascularmortalityorcancer.Thereisasmall
increaseinriskofdevelopingdiabetesbutthebenefitsofcholesterolloweringgreatlyexceedanyriskassociated
withdiabetes.Ifstatinintolerancedevelops,astepwisestrategyinvolvingswitchingagentsandredosingis
recommended.DespitelowHDLclevelscontributingtoCVDrisk,drugtherapytoraiseHDLhasnotbeenshownto
reduceCVDriskandisnotcurrentlyindicated.
Cholestyramine(OptionA)isincorrect.Cholestryamineisusedintrulystatinintolerantpatientsandthereforeisnotthe
correctanswer
Dieticianadvice(OptionB)isincorrect.Hehasalreadyhadapatientlifestylemodificationandthereforedieticianadvice
isnotthebestanswerhere.
Fibrate(OptionC)isincorrect.Fibrateshavelimitedimpactoncholesterollevels.
Nicotinicacid(OptionD)isincorrect.Nicotinicacidisnowunavailableforclinicuse.
41943
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Question4of295
An82yearoldmanpresentstotheCardiologyClinicwithsyncopalattacks.HisGPhasbeentreatinghimforworsening
hypertensiveheartfailure.Hetakesfurosemide,80mgandramipril,10mg,withtherecentadditionofasmalldoseof
spironolactone.Around2weeksagohepresentedwithananginaattacktotheEmergencyDepartmentaftergettingchest
painwhilstoutshoppingatthesupermarket.OnexaminationhisBPis165/122mmHg.Hispulseis92bpm,heartsounds
revealasystolicmurmurloudestintheaorticarea,butnoejectionclick.Hehasbibasalcracklesonauscultationofthe
chest.Thetablebelowcontainsinvestigationresults.
Hb 12.9g/dl
WCC 5.9109/litre
PLT 189109/litre
Na+ 138mmol/litre
K+ 5.4mmol/litre
Creatinine 201mol/litre
ChestXray Bilateralbasalinfiltratesconsistentwithfluid,andcardiomegaly
Whichoneofthefollowingisthemostlikelycauseofhisaorticstenosis?
A Subacutebacterialendocarditis
B Rheumaticfever
C Bicuspidaorticvalve
D Malformedtricuspidaorticvalve
E Seniledegenerativeaorticstenosis
Explanation
Seniledegenerativeaorticstenosis
Seniledegenerativeaorticstenosisinvolvesprogressivecalcificationofthevalveleaflets,inresponsetolong
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standinghaemodynamicstress
Itrepresentsthecommonestcauseofaorticvalvereplacement,usuallypresentingaftertheageof75
Diabetesandhypercholesterolemiaareriskfactorsfordevelopmentofthelesion
Patientswithseniledegenerativeaorticstenosismaywellhavecoexistentcoronaryarterydisease,inwhichcase
coronaryarterybypasssurgerycanbecarriedoutatthesametimeasvalvereplacement
Othernotes
Rheumaticfeverrelatedaorticstenosistendstopresentearlierinpatientsintheirsixties
Congenitalbicuspidaorticstenosispresentsinpatientsinthe4050yearagebracket
22495
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Question5of295
Earlyonsetaorticstenosisinadultsshouldbeanticipatedinwhichofthefollowingconditions?
A Bicuspidaorticvalvedisease
B Leftventricularmembrane
C Hypertrophicobstructivecardiomyopathy
D Rheumatoidarthritis
E Infectiveendocarditis
Explanation
TheanswerisBicuspidaorticvalvedisease
Bicuspidaorticvalvedisease
Approximately1%ofthegeneralpopulationhasabicuspidaorticvalvedefect.Thenormalaorticvalveistrileaflet
thatis,ithasthreeleafletswhich,whenclosed,createlinessimilartotheMercedesBenzlogo.Bicuspidvalvesare
whentwooftheleafletshavebecomefused(sometimesleavingavisibleraphedemonstratingthefusion)during
earlydevelopmentoronlytwodistinctleafletsformed.Thisoccursduetogeneticanddevelopmentalabnormalities
andiscommonlyassociatedwithaorticdilatation.1030%haveafamilialformanditisalsostronglyassociated
withaorticcoarctation(50%ofcoarctationpatientshavebicuspidvalvesalthoughfewbicuspidpatientshave
coarctation).ItisalsostronglyassociatedwithTurnerandWilliamsyndromes.Thebicuspidaorticvalvemay
functionnormallythroughoutlife,buttheleafletsdemonstrateanearlieronsetoffibrocalcificthickeningthanseen
innormalvalvesthiswillresultinaorticstenosisatalmostadecadeearlierthantypicalaorticstenosis.
Leftventricularmembrane(OptionB)isincorrect.Leftventricularmembranesdonotaffecttheaorticvalveperseand
althoughtheremaybeanejectionsystolicmurmur,thevalveitselfisnormal.
Hypertrophicobstructivecardiomyopathy(OptionC)isincorrect.Hypertrophiccardiomyopathyalsocreatesanejection
systolicmumur,butthisisduetoassymetricalhypertrophyoftheseptumandsystolicmovementoftheanteriormitral
valveleaflettocreateadynamicobstructiontoflow.Theaorticvalveitselfisnormal.
Rheumatoidarthritis(OptionD)isincorrect.Rheumatoidarthritisisnotassociatedwithaorticstenosispatientsmay
developaorticrootdilatation,asseeninmanyconnectivetissuedisorders,andthiswouldcauseaorticregurgitation.The
questionisalsoanadditionaltrickthecandidatemaymisreaditasrheumaticfeverandselectitasananswer.Even
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rheumaticfeveritselfisnotacauseofaorticstenosisrather,theexposuretothestreptococcalillnesstriggersan
autoimmuneresponsethatdamagestheheartvalvestocauserheumaticheartdisease.Anyvalvecouldbeaffectedbythis
condition.
Infectiveendocarditis(OptionE)isincorrect.Infectiveendocarditisismorelikelytocausevalvedestructionand
regurgitationthanstenosis.
41949
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Question6of295
A64yearoldwomansuffersfromfrequentandpainfulurinarytractinfections.Shedrinkscranberryjuicetocounterthe
UTIs.Shehasparoxysmalatrialfibrillation,forwhichshetakeswarfarinandamiodarone.Pastmedicalhistoryincludes
hypertension,forwhichshetakesramiprilandbendroflumethiazide,andhypercholesterolaemia,forwhichshetakes
simvastatin.
Whichoneofhermedicationsismostlikelytointeractwiththecranberryjuice?
A Amiodarone
B Bendroflumethiazide
C Ramipril
D Simvastatin
E Warfarin
Explanation
TheanswerisWarfarin
WarfarininteractionsarecommonlyassessedintheMRCPexamination.Cranberryjuicecontainsanumberof
bioflavinoids,someofwhicharethoughttocauseinhibitionofthecytochromep4502C9isoenzyme,whichis
responsibleforwarfarinmetabolism.Thereforecranberryjuicecanprolongtheeffectofwarfarinandincreasethe
INR.
ThewarfarininteractionwasgivenasaCommitteeforSafetyofMedicines(CSM)warningin2003andhas
featuredprominentlyintheMRCPexaminationpatientsshouldbemadeawareofavoidingregulardrinking
ofcranberryjuice.
Cranberryjuicealsointeractstoalesserdegreewithamitriptyline,diazepam,NSAIDs,fluvastatin,losartan
andirbesartan.Itdoesnotinteractwithramiprilorsimvastatin.
Metabolismofsimvastatinandamiodaroneareinhibitedbygrapefruitjuiceratherthancranberryjuice.
Amiodarone(OptionA)isincorrect.Amiodaronemetabolismisinhibitedbygrapefruitjuiceasdescribed.
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Bendroflumethiazide(OptionB)isincorrect.Bendroflumethiazidedoesnotinteractwithcranberryjuice.
Ramipril(OptionC)isincorrect.Asdescribedramiprildoesnotinteractwithcranberryjuice.
Simvastatin(OptionD)isincorrect.Simvastatinmetabolismisinhibitedbygrapefruitjuice.Asdescribedwarfarindoes
notinteractwithsimvastatin.
42037
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Question7of295
A67yearoldmanisadmittedforchestpainandraisedtroponinlevels.HisECGonadmissionshowedSTdepression
whichresolvedafterantianginaltherapy.Hehasbeenasymptomaticforthepast12hourswithnonewECGchanges.
EchocardiographyshowsnormalLVfunction.
Intermsoffurtherassessment,whatwouldyoudonext?
A Inpatientcoronaryangiography
B Radionuclideangiogram
C Outpatientexercisestresstest
D Inpatientexercisestresstest
E Dischargehomeonmedications
Explanation
TheanswerisInpatientcoronaryangiography
Basedonhisage,elevatedtroponinanddynamicECGchangesheisatleastatintermediateriskofdeathand
myocardialinfarctionoverthenext6monthsbyeithertheTIMIorGRACEriskscoringsystems.Consequentlyhe
shouldbeofferedcoronaryangiography(withfollowonPCIifindicated)within96hoursofadmission(NICE
guideline94).Itiscommonfortheadmissionhospitaltonothaveacardiaccatheterlabandtherewillbe
arrangementswithacentralhospitalforintervention.
Radionuclideangiogram(OptionB)isincorrect.Asthemajorityofriskoccursearlythisisnotappropriatehere.
Outpatientexercisestresstest(OptionC)isincorrect.Themajorityofriskoccursearly,henceoutpatientinvestigations
arenotappropriate.
Inpatientexercisestresstest(OptionD)isincorrect.Historically,suchpatientswillhavebeenriskstratifiedwithanin
patientexercisetestwhenthebarriertoangiographywashigher,butthispatienthashigherriskfeatures.
Dischargehomeonmedications(OptionE)isincorrect.Asthemajorityofriskoccursearlythisisnotappropriatehere.
41870
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Question8of295
A65yearoldmanwithchronicrenalfailurehasaserumpotassiumlevelof7.1mmol/litre(normal3.55.5mmol/litre).
WhatwouldbethemostcharacteristicfindingonECG?
A NarrowQRScomplexes
B PeakedTwaves
C ProlongedQTintervals
D ProminentUwaves
E Twaveinversion
Explanation
TheanswerisPeakedTwaves
ECGfindingsduringhyperkalaemia
Hyperkalaemiacauseshyperpolarisationofcellmembranes,leadingto
decreasedcardiacexcitability
hypotension
bradycardia
eventualasystole
TheECGshowscharacteristic,tall,peakedTwaveswithwidenedQRScomplexes:theECGbecomesprogressively
widerandmoresinusoidalwithbradycardiaandlossofalltypicalQRSfeatures.Thereisaprogressivediminutionin
theamplitudeofthePwave,whicheventuallydisappears.Asystoleusuallyresultsshortlyafter.Thepresenceoftall,
peakedTwavesishighlycharacteristicandthereforeisthecorrectanswer.
NarrowQRScomplexes(OptionA)isincorrect.TheQRScomplexesarewidenedinhyperkalaemia.
ProlongedQTintervals(OptionC)isincorrect.ProlongedQTintervalsarenotthecharacteristicfeatureinhyperkalaemia
prolongedQTcanbeseenin
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acutemyocardialinfarction
hypocalcaemia
hypothermia
procainamideadministration
ProminentUwaves(OptionD)isincorrect.ProminentUwavesareafeatureofhypokalaemia.
Twaveinversion(OptionE)isincorrect.Twaveinversionisafeatureofischaemicheartdisease.
41951
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Question9of295
A21yearoldwomanpresentstotheclinicwithsymptomsofincreasedshortnessofbreathanddecreasedexercise
tolerance.Sheusedtobeakeenhockeyplayerwhenatschoolbutisnowvirtuallyunabletoevenwalktothebusstop
withoutbecomingshortofbreath.Onexaminationshelookstiredandslightlyshortofbreathatrest.HerBPiselevatedat
145/92mmHg.EchocardiogramshowedincreasedrightatrialsizeandelevatedrightarterialpressurebyDoppler.Cardiac
catheterizationresultswereasfollows:
O2saturationSVC74%
O2saturationRA82%
O2saturationRV82%
O2saturationLA91%
O2saturationLV91%
Whichoneofthefollowingisthemostlikelydiagnosis?
A Ostiumprimumatrialseptaldefect
B Secundumatrialseptaldefect
C Patentductusarteriosus
D Pulmonarystenosis
E Tricuspidregurgitation
Explanation
Secundumatrialseptaldefect
Secundumdefectsmayoftenbediagnosedinpatientsenteringearlyadulthood
ThedifferenceinsaturationsbetweentheSVCandtherightventricleindicatesthatthereisalefttorightshuntof
oxygenatedblood
Patientswithsecundumdefectstendtobeslimandtonotsufferfromcyanosis
Therapyofchoiceisviadeliveryofacatheterdevicetoclosethedefect,orsurgicalclosureifthedefectis
particularlylarge
20924
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Question10of295
A50yearoldmanpresentstothecardiologyclinicforreview.Hisbrotherdiedsuddenlyofacardiacarrestwhileplaying
Sundayleaguesoccer,andwasfoundonpostmortemtohaveanunderlyingdiagnosisofhypertrophicobstructive
cardiomyopathy(HOCM).WhichoneofthefollowingisthemostappropriatewaytoruleoutHOCM?
A ExerciseECG
B Electrocardiographystudies
C Transoesophagealecho
D Radionucleotidescanning
E Resting12leadECG
Explanation
Screeningforhypertrophicobstructivecardiomyopathy
Twodimensionalechocardiographyisdiagnosticforhypertrophicobstructivecardiomyopathy(HOCM),with
transoesophagealechodeliveringthebestviews
Echocardiographyfindingsareasfollows
elevatedflowvelocityacrosstheleftventricular(LV)outflowtractisseen
diastolicdysfunctionwithreducedleftventricularcompliance
systolicanteriormotionoftheanteriormitralvalveleaflet
asymmetricalseptalhypertrophy
Radionucleotideimagingmayshowreversibleperfusiondefects,butthesearenotdiagnosticofthecondition
Cardiaccatheterisationfollowsechocardiography,toassessthedegreeofLVoutflowtractobstruction,LV
anatomyandcoronaryarteryanatomy
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Question11of295
YouareworkinginthechemicalpathologylaboratoryandreceiveasamplerequestforanalysisofBNP.Youdonthave
anyclinicaldetailsontheformapartfromchestpain.YouplantoringtheSHOwhorequestedthetestforfurther
details.InwhichoneofthefollowingsituationsisBNPmostlikelytobenormal?
A Unstableangina
B Constrictivepericarditis
C Pulmonaryembolus
D Acutemyocardialinfarction
E Acutemitralvalverupture
Explanation
Btypenatriureticpeptide
Btypenatriureticpeptide(BNP)issecretedinresponsetoraisedintracardiacpressures,primarilyowingto
volumedistension,andleadstoincreasedsodiumexcretionanddecreasedsystemicvascularresistance
Bothacutemyocardialinfarctionandacutemitralvalverupturemayresultinvolumedistension,leadingto
elevatedlevelsofBNP
ConstrictivepericarditismayalsoleadtoraisedintracavitypressuresandhenceelevatedBNP
LargepulmonaryembolusproducesraisedrightsidedcardiacpressuresandthusmayleadtoelevatedBNP
UnstableanginadoesnotusuallyleadtoalteredlevelsofBNP
20918
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Question12of295
A32yearoldmanisrecentlydiagnosedwithankylosingspondylitis.Echocardiogramshowsavalvularabnormality.
Whichoneofthefollowingisthemostlikelydiagnosis?
A Aorticregurgitation
B Aorticstenosis
C Mitralregurgitation
D Mitralstenosis
E Tricuspidstenosis
Explanation
TheanswerisAorticregurgitation
Ankylosingspondylitisisstronglyassociatedwithaorticregurgitation(occursin4%ofcases).Anaortitisleadsto
aorticrootdilatationwithsubsequentfailureofleafletcoaptation.Thiscausesaorticregurgitation.Itcanalsooccur
inotherinflammatorydisorderssuchasrheumatoidarthritis.Theothervalveconditionslisteddonothaveaspecific
linktoankylosingspondylitisandhencearenotthecorrectanswer.
Chronicaorticregurgitation
Causesandassociations
Rheumaticheartdisease
Syphilis
Seronegativearthritides,includingankylosingspondylitis
severehypertension
congenitalbicuspidaorticvalve
aorticendocarditis
Marfansyndrome
osteogenesisimperfecta
Signs
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Boundingorcollapsingpulse(detectedatradialpulse).
Awidepulsepressure(eg180/50).
Eponymoussignsthataccompanytheboundingorcollapsingpulse:
Corriganssignvisibleandvigorousarterialpulsationsinneck
DeMussetsignheadnoddingduetothearterialpulsationsintheneck
Quinckesigngentleandsubtlepulsationofthecapillarybedinnails
Duroziezsigndiastolicmurmurproximaltofemoralarterycompresson(duetoflowreversal).
Earlydiastolicmurmurbestheardalongtheleftsternaledgeaccentuatedduringexpiration.
NotethatthereisoftenanaorticsystolicflowmurmurbecausethereisanincreasedvolumeofbloodintheLVdue
totheregurgitation.
Severityisindicatedbythepresenceofacollapsingpulse,awidepulsepressureandpulmonaryoedema.
Investigations
ChestXraytoassesscardiacsize.
Electrocardiograph(ECG).
Echocardiogramisthemostimportanttestaorticregurgitationhastobeassessedusingavarietyof
parameters,andnosingleparameteraloneisaperfectmeasure.Commonfactorsincludethewidthanddepth
ofthejetoncolourDoppler,thepressurehalftimeandwhetherthereisdiastolicflowreversalintheaorta.
Cardiaccatheterisationmaybeperformedifthereisdoubtovertheseverityoftheregurgitationseverityis
estimatedbythedegreeofcontrastthatfillstheventriclesafterinjectionintotheaorticroot.
Treatmentindications
Betablockersshouldbeavoidedastheseprolongdiastoleandthereforewouldincreasetheregurgitant
fraction.
Valvereplacementisindicatedbeforetheappearanceofsignificantleftventricularfailure,asvalve
replacementbeforetheonsetofsymptomsisassociatedwithamuchmorefavourableprognosis.
Aorticstenosis(OptionB)isincorrect.Asdescribedthereisnospecificlinktoankylosingspondylitis.
Mitralregurgitation(OptionC)isincorrect.Asdescribedthereisnospecificlinktoankylosingspondylitis.
Mitralstenosis(OptionD)isincorrect.Asdescribedthereisnospecificlinktoankylosingspondylitis.
Tricuspidstenosis(OptionE)isincorrect.Asdescribedthereisnospecificlinktoankylosingspondylitis.
41997
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Question13of295
A36yearoldwomanwhois8weekspregnantpresentswithaswollenleftleg.Dopplerstudiesconfirmadeepvein
thrombosis.
Whatwouldbethemanagementinthiscase?
A Commenceintravenousheparin
B Startsubcutaneousheparinthroughoutpregnancy
C Oralanticoagulationwithwarfarindailythroughoutpregnancyandthepostpartumperiod
D Aspirin300mgdailythroughoutpregnancyandthepostpartumperiod
E Elasticbandcompressofherleftleg,bedrestandfootelevation
Explanation
TheanswerisStartsubcutaneousheparinthroughoutthepregnancy
Thisoptionmitigatestheriskofdevelopmentalabnormalitiesfromwarfarinduringorganogenesis.
Commenceintravenousheparin(OptionA)isincorrect.ContinuousIVheparinfortheremaining32weekswouldbe
impracticableandthereisahigherriskofheparininducedthrombocytopenia(HIT)withunfractionatedheparin(13%)as
comparedtoaLMWH(0.1%).
Oralanticoagulationwithwarfarindailythroughoutpregnancyandthepostpartumperiod(OptionC)isincorrect.
Warfariniscontraindicatedinthefirsttrimesterasitisteratogenic.
Aspirin300mgdailythroughoutpregnancyandthepostpartumperiod(OptionD)isincorrect.Highdoseaspirinis
contraindicatedinpregnancyasitcancauseprematureductalclosure.
Elasticbandcompressofherleftleg,bedrestandfootelevation(OptionE)isincorrect.Anticoagulationisessential,and
thereforeoptionEisincorrect.
41869
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Question14of295
Duringaroutinemedicalcheckup,a2yearoldboyhasbeenfoundtohaveacontinuousmachinerymurmuron
auscultationjustbelowtheleftclavicle.
Giventhelikelydiagnosis,whatwouldbethemostcharacteristicinvestigativefindinginthispatient?
A Dilatedleftventricleonechocardiogram
B HilarhazinessonchestXray
C Polycythaemia
D ProminentpulmonaryarteryandpulmonaryplethoraonchestXray
E RightventricularhypertrophyonECG
Explanation
TheanswerisDilatedleftventricleonechocardiogram
Diagnosingductusarteriosus
Thepresenceofacontinuousmachinerymurmurisveryconsistentwithapersistentductusarteriosus.
Becausetheaorticpressureexceedsthepulmonaryarterypressurethroughoutacardiaccycle,apersistentductus
producescontinuouslefttorightshuntingandacontinuousmachinerymurmur.
ThepresenceofadilatedLVonechocardiogram,togetherwiththemurmur,arecharacteristicfeaturesofductus
arteriosusandhenceAisthecorrectanswer.
ECGchangeswouldbeconsistentwiththefollowingscenarios.
HilarhazinessonchestXray(OptionB)isincorrect.Hilarhazinessisafeatureofpulmonaryoedemaandthisisnot
specifictothiscondition.
Polycythaemia(OptionC)isincorrect.Polycythaemiamayoccuriftheshuntisreversed(Eisenmengersyndrome)and
representsanattempttocompensateforrelativehypoxiaduetodeoxygenatedbloodenteringthesystemiccirculation.The
increaseinHbconcentrationcontributestoanevenlargerquantityofrelativelydeoxygenatedbloodandtheappearanceof
cyanosisinEisenmengers.
ProminentpulmonaryarteryandpulmonaryplethoraonchestXray(OptionD)isincorrect.Aprominentpulmonary
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arterymaybeseenonchestXrayinpersistentductus,butthepresenceofpulmonaryplethoraismoresuggestiveofatrial
septaldefect.Notethatthetermplethorasuggeststhereareincreasedlungvesselmarkingsthroughoutthelungfieldand
thisisafeatureofASDupperlobediversioncanappearsimilar,butismostlyintheupperlungfieldsandcanoccurwith
anycauseofpulmonaryoedema.
RightventricularhypertrophyonECG(OptionE)isincorrect.Thecontinuousshuntingintothepulmonaryarterycauses
increasedpulmonaryvenousreturntotheleftheartandanincreasedleftventricularvolumeload,whichthenmanifests
withLAandLVdilatation.Therightheartisnotaffecteduntillateintothediseaseandwouldnotbepresentina2year
old.
41959
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Question15of295
A67yearoldmancomestotheclinicforreview.Hehassufferedepisodesofcentralchestpainon3occasionsoverthe
pastyear,whichhaveoccuredtwicewhenhewentoutonacoldmorninginthewinter,andoncewhenhewascarryinga
treetrunkwhichhadbeenchoppeddowninhisgarden.Onalloftheoccasionsthepainlastedforafewminutesandthen
subsidedspontaneouslywhenherested.Hesmokes5cigarettesperdayandhasahistoryofhypertensionmanagedwith
Ramipril10mgdaily.HeisalsotakingAspirin75mgforprimaryprevention.OnexaminationhisBPis135/72mmHg,
pulseis72/minandregular.HisBMIis25.
Investigations
Hb 13.1g/dl
WCC 8.9x109/l
PLT 203x109/l
Na+ 138mmol/l
K+ 4.9mmol/l
Creatinine 100micromol/l
Totalcholesterol 6.2mmol/l
Glucose 6.2mmol/l(fasting)
Whichofthefollowingistheoptimalmanagementwithrespecttoischaemiccardiovasculareventprevention?
A Atenolol
B Atorvastatin
C Clopidogrel
D Isosorbidedinitrate
E Metformin
Explanation
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TheanswerisAtorvastatin
Thispatientssymptomsareconsistentwithchronicstableangina.Withrespecttocardiovascularriskfactorsheshouldof
coursebeencouragedtostopsmoking,andtoexerciseandloseweightifpossiblegiventhathehasimpairedfasting
glucose.Metformininthissituationisnotindicated.WhilstAtenololorIsosorbidedinitratemayreducetheriskoffuture
attacksofangina,theyarenoteffectiveinreducingtheriskoffutureischaemiceventscomparedtoAtorvastatin,the
correctanswerhere.ClopidogrelisusedincombinationwithaspirininthemanagementofACSandpostcoronaryartery
stenting.
36433
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Question16of295
A30yearoldmanisbeinginvestigatedforhypertension.AcombinationofBPsestimatedbycolourflowDopplerand
measuredvaluesarelistedinthetablebelow:
LV 200/10mmHg
Ascendingaorta 200/70mmHg
Rightarm 190/70mmHg
Rightfemoralartery 110/70mmHg
Whichoneofthefollowingisthemostlikelydiagnosis?
A Coarctationofaorta
B Leftsubclavianarterystenosis
C Aorticregurgitation
D Aorticstenosis
E HOCM
Explanation
Coarctationofaorta
Thispicturewouldbetypicalofcoarctationdistaltotheoriginofthebrachiocephalicartery
Cardiaccatheterisationisthenextmostappropriatestepinfurthercharacterisingthepressuregradientacrossthe
coarctation,MRIscanning
Prognosisaftercoarctationisdependentonspeedofdiagnosis
Inthosediagnosedaftertheageof35years,survivaltoage50isonly20%,whereasdiagnosisandtreatmentasa
childisassociatedwithasurvivalabove90%
20712
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Question17of295
A60yearoldmanwithunstableanginaonlongtermdigoxinwasbeingmonitoredonthewardwithtelemetry,whenthe
monitordisplayedatachycardiaof180bpm.TheprintoutshoweddiscretenormalmorphologyPwavesbeforeeachQRS
complexandtherewasanaccelerationintherateafterinitiationofthearrhythmia.TheQRSwidthwas0.12s.
Whichoneofthefollowingisthemostlikelyarrhythmia?
A Automaticsupraventriculartachyarrhythmias
B AVnodalreentranttachycardia
C Bypasstractmediatedmacroentranttachycardia
D Intraatrialreentry
E Ventriculartachycardia
Explanation
TheanswerisAuatomaticsupraventriculartachyarrhythmias
Automaticsupraventriculararrhythmiascharacteristicallyshowawarmupphenomenonthatis,therateaccelerates
afteritsinitiation.Inthescenario,thearrhythmiaisseentospeedupafterinitiation,makingthisthecorrectanswer.
AVnodalreentranttachycardia(OptionB)isincorrect.AVnodalreentranttachycardia,bypasstractmediated
macroentranttachycardiaandintraatrialreentryarealltypesofreentrantsupraventriculararrhythmiasinAVnodalre
entranttachycardia,Pwavesareusuallyofabnormalmorphology(inverted)sincethequestionstatesthePwavesare
normal,theanswercannotbeAVnodalreentranttachycardia.
Bypasstractmediatedmacroentranttachycardia(OptionC)isincorrect.ThenormalPwavesrulethisoptionouthereas
described.
Intraatrialreentry(OptionD)isincorrect.InintraatrialreentrySVTstherearediscretePwaves,butthereisnowarm
upphenomenonandsothiscannotbetheanswerhere.
Ventriculartachycardia(OptionE)isincorrect.ThenormalQRSwidthrulesoutaventriculartachycardiawhichare
typicallyverybroadduetoabnormalconductioninthemyocardiumratherthanthroughspecialisedconductingtissues.
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Question18of295
A55yearoldobesewomanpresentstotheEmergencyDepartmentwithworseningdyspnoeaandankleswellingdueto
endstageheartfailure.HerBPinthedepartmentismeasuredat135/72mmHg,herpulseis79/minandregular.Thereare
cracklesuptothemidzonesbilaterallyonauscultationofherchest,andbilateralpittingoedematotheknees.
Investigationsrevealacreatinineof155mol/litre.
Whichoneofthefollowingcombinationsofdrugsisbestsuitedforherintermsofrelievingsymptomsandmortality
benefitonceherfluidbalancehasbeenappropriatelymanaged?
A Ramipril,amlodipineandbendrofluazide
B Ramipril,amiloride,furosemideandatenolol
C Ramipril,furosemideandamlodipine
D Ramipril,furosemideandatenolol
E Ramipril,furosemide,bisoprololandspironolactone
Explanation
TheanswerisRamipril,furosemide,bisoprololandspironolactone
Thepatienthasknownheartfailureandpresentedacutelyinpulmonaryoedema.Sheshouldbetreatedwith
furosemideforprimarilysymptomaticimprovement.Thereisstrongrandomisedoutcomeevidencefortheaddition
ofanACEinhibitor(ramipril),andcardioselectiveblockers(bisoprolol),andaldosteroneantagnoists
(spironolactone).Althoughshehasanelevatedcreatinine,thisinitselfshouldnotpreventtheattemptedinitiation
anduptitrationofanACEinhibitorandaldosteroneantagonist.NICErecommendsthatdosesareuptitratedat
intervalsofnolessthan2weeks.Acceptablechangesinrenalfunctionareuptoa30%increasefrombaseline
creatinineora25%reductionfrombaselineeGFR.Ifserumpotassiumrisestoabove6mM,thedoseshouldbe
reduced.
IfthepatienthasasignificantlyprolongedQRSduration,aleftbundlebranchblock(LBBB)insertionofa
biventricularpacemaker(cardiacresynchronisationtherapy)shouldbeconsideredonceoptimalmedicaltherapyhas
beenachievedandthepatientremainsNHYAIIIorIV.
Ramipril,amlodipineandbendrofluazide(OptionA)isincorrect.Thisoptiondoesnotincludealloftherecommended
therapies.
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Ramipril,amiloride,furosemideandatenolol(OptionB)isincorrect.Thisoptiondoesnotincludealloftherecommended
therapies.
Ramipril,furosemideandamlodipine(OptionC)isincorrect.Thisoptiondoesnotincludealloftherecommended
therapies.
Ramipril,furosemideandatenolol(OptionD)isincorrect.Thisoptiondoesnotincludealloftherecommendedtherapies.
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Question19of295
A32yearoldmanpresentstotheclinicwithshortnessofbreath,whichisparticularlybadwhenhegoesjogging.Hehas
recentlyincreasedhisexercisetotryandreducehisweight.Onacoupleofoccasionshehasalsonoticedsomechest
discomfort,whichhascausedhimtostopexercising.OnexaminationhisBPis150/88mmHg,andhehasadoubleapical
impulse.Onauscultationthereisaharshmidsystolicmurmur,whichisloudestbetweentheapexandtheleftsternal
border.Clinicalresultsaregiveninthetablebelow:
Hb 13.0g/dl
WCC 4.8109/l
PLT 199109/l
Na+ 140mmol/l
K+ 5.0mmol/l
Creatinine 100mol/l
ECG LVHandwidespreadQwaves
Whichoneofthefollowingismostdirectlycorrelatedwithincreasedriskofsuddendeath?
A Increasedleftventricularoutflowtractgradient
B Presenceofmitralregurgitation
C Degreeofseptalhypertrophy
D Presenceofatrialfibrillation
E Systolicanteriormotion
Explanation
Suddencardiacdeath
Anumberofstudieshaveattemptedtoexaminepotentialcorrelationsbetweenclinicalfeaturesofhypertrophic
obstructivecardiomyopathy(HOCM)andincreasedriskofsuddencardiacdeath
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JAmCollCardiol,200341:994996,doi:10.1016/S07351097(02)030036isagoodreviewoftherelevantdata
Oftheoptionsgiven,degreeofventricularseptalhypertrophyappearstobemoststronglylinkedtoincreasedrisk
ofsuddendeath
OtherpublicationsalsopointtoLVHperseasbeingariskfactor
Othernotes
PatientswithHOCMusuallydiefromarrhythmias,andpreviousventriculartachycardiaisthusstronglypredictive
oftheriskofsuddendeath
Increasedoutflowtractgradientappearstoberelatedtosymptomssuchasshortnessofbreathandangina
Myomectomy,takingtissuefromtheinterventricularseptum,appearstoimprovethesesymptoms
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Question20of295
Apatientpresentswithshortnessofbreathandankleswelling.Anechocardiogramhasbeenorderedtodeterminetheleft
ventricularejectionfraction.
Whichoneofthefollowingechocardiographymodesisthemostappropriate?
A Mmode
B Amode
C Moderntransthoracic
D Continuouswave
E Powerwave
Explanation
Echocardiography
Transthoracicechocardiography
Moderntransthoracicechocardiographycombinesrealtimetwodimensionalimagingofthemyocardiumand
valveswithinformationaboutvelocityanddirectionofbloodflowobtainedbyDopplerandcolourflowmapping
Itisnoninvasive,andacompleteexaminationcanbeperformedinmostpatientsinlessthan30min
Mmodeechocardiography
Mmodeechocardiographyhasprecededmoderntwodimensionalimaging
Unliketwodimensionalimaging,whichusesaseriesofsweepsacrosstheheart,Mmodeusesasinglestatic
beamofveryfrequentultrasoundpulses
Thenarrowbeamisanalogoustoaverticalmineshaftpassingthroughvariouslayersofrock
Displayedinrealtime,thisresultsinreflectionsfromcardiacstructuresbeingdisplayedashorizontallineswith
superficialstructuresatthetopofthescreenandthedeeperstructuresatthebottom
Thesedataareinterpretablewhenoneknowswhichstructureeachlinerepresents,andthetechniquehasexcellent
spatialresolution
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Question21of295
A17yearoldyoungmanpresentswithpalpitations.Hisphysicalexaminationisnormalexceptforasystolicmurmurin
thesecondleftintercostalspaceandprominentprecordialmotionwithalatesystolicimpulse.
Whichoneofthefollowingconditionsishemostlikelytohave?
A Aorticstenosis
B Atrialseptaldefect
C Hypertrophiccardiomyopathy
D Mitralvalveprolapse
E Mixedaorticvalvedisease
Explanation
Diagnosinghypertrophiccardiomyopathy
Amidtolatesystolicimpulseintheprecordialmotion(tripleripple)isseeninpatientswithhypertrophic
cardiomyopathy
AhyperdynamicimpulseisseeninmildtomoderateAR
Aorticstenosis,atrialseptaldefect,mitralvalveproplapseandmixedaorticvalvediseasecanproducethemurmur
butnotthischaracteristicfinding
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Question22of295
AnelderlymanisbroughttotheEmergencyDepartmentbyparamedicambulanceafteracollapse.Heisknowntohave
ischaemicheartdisease.PeripheralpulsesareabsentandECGrevealswidecomplextachycardia.Hehasapparentlybeen
conversantwiththeambulancestaff,butisnowverysleepy.Youmanagetoelicitacarotidpulse,whichseemstobe
around200bpm,andtheelectronicBPmachinemeasureshisBPas70/40mmHg.
Immediatemanagementconsistsofwhichoneofthefollowing?
A Programmedstimulation
B ThrombolysiswithTPAorstreptokinase
C Abolusdoseofintravenouslidocaine
D DCcardioversion
E Intravenousphenylephrineandcarotidsinuspressure
Explanation
TheanswerisDCcardioversion
Ventriculartachycardia(VT)
Thepatienthasventriculartachycardiaandishaemodynamicallyunstablehisbloodpressureislowandiscausing
alossofconsciousness.ThemostappropriatetreatmentisanurgentDCcardioversion.
ManagementofVT
Immediatetreatmentconsistsofcardioversionfollowedbyasuitableantiarrhythmicsuchasamiodaroneinfusion
firstline,orifpersistentVTdespiteamiodaronethenaninfusionoflignocaine(lidocaine).ThetriggerofVTmust
beidentifiedandtreatedimmediatelyincludingelectrolyteimbalanceorcardiacischaemia.Mostofthesepatients
shouldundergocoronaryangiographytoexcludeanischaemiacausingstenosis.
Myocardialinfarction(MI)maybethecauseoftheventriculartachycardia,hencetreatmentforMIwouldbe
indicatedif,aftertreatmentoftheVT,thereareclearsignstosupporttheneedofprimaryPCI(preferred)or
thrombolysis(ifPPCIunavailableortimedelaysmakeitfutile).
Programmedstimulationmayonlybecarriedoutwhenthepatientisstableandisperformedinvasivelyinthe
electrophysiologysuite.
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Programmedstimulation(OptionA)isincorrect.Thisisadiagnostictechniqueusedduringinvasiveelectrophysiological
studiestodeterminethesourceofVTbeforedeliveringinvasivetherapies.Thiscannotbecorrectduringanemergency
situation.
ThrombolysiswithTPAorstreptokinase(OptionB)isincorrect.Thismaybeappropriateiftherewasevidenceofa
myocardialinfarctiontriggeringtheVT.However,theVTmustbetreatedrapidlyfirstbecauseitdegeneratesintoVFand
thepatientdies.
Abolusdoseofintravenouslidocaine(OptionC)isincorrect.LidocaineisusedforhaemodynamicallystableVTbutit
issecondline,andshouldbeusedafteramiodaroneintheformofaninfusion.
Intravenousphenylephrineandcarotidsinuspressure(OptionE)isincorrect.Therearedatatosuggestthatacombination
ofIVphenylephrine(whichtriggersareflexincreaseincardiacvagaltone)andcarotidsinusmassage(anotherdriverof
increasedvagaltone)canterminateVTinsomepeople.However,thiswouldnotbethefirstlinetreatmentinapatientin
haemodynamiccompromise.
41895
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Question23of295
Youreviewa68yearoldwomanwhopresentswithasuddenepisodeofcollapsewhiletakingcommunioninchurch.This
hasbeenherthirdsyncopalepisode.Pastmedicalhistoryofnoteincludesrecentlydiagnosedseverehypertension,for
whichherGPhascommencedenalapriltherapy.Onexaminationherbloodpressureis160/130mmHg,shehasleft
ventricularhypertrophyonclinicalexaminationandaloudejectionsystolicmurmur.Auscultationofthechestreveals
bibasilarcracklesconsistentwithmildheartfailure.Whichoneofthefollowingisthedefinitiveinvestigationofchoice
forthispatient?
A ChestXray
B Electrocardiogram(ECG)
C Echocardiogram
D Cardiaccatheterisation
E 24hHoltermonitor
Explanation
Aorticstenosis
Thispatientissufferingfromsymptomaticaorticstenosis,asevidencedbythehistoryofsyncope,hypertension,
leftventricularhypertrophyandharshejectionsystolicmurmur
Althoughechocardiographywillaidindiagnosis,gradientacrosstheaorticvalvemaybeunderestimatedbecause
ofthepossibilityofmultipleechosignalsandcoexistentleftventriculardysfunction
Assuch,cardiaccatheterisationisthedefinitiveinvestigation,asitallowsformoreaccurateestimationofvalve
gradientandcharacterisationofcoexistentcoronaryarterydisease,whichmayrequireinterventionatthesame
time
8291
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Question24of295
A54yearoldwomanwithahistoryofatrialfibrillationpresentswithleftfaceandarmweaknessconsistentwithastroke.
OnexaminationherBPis162/82mmHg,withapulseof85bpm,irregular.Clinicalresultsaregiveninthetablebelow:
Hb 12.1g/dl
WCC 5.4109/l
PLT 175109/l
Na+ 140mmol/l
K+ 5.0mmol/l
Creatinine 105mol/l
CThead noevidenceofintracerebralhaemorrhage
Sixhourspoststrokeyouareconsideringanticoagulationorantiplatelettherapy.Whichoneofthefollowingwouldbe
mostappropriate?
A Fullivheparinisation
B Lowmolecularweightheparinandcommencewarfarintreatment
C Alteplase
D Aspirin
E Streptokinase
Explanation
Stroke
ThispatientisoutsidethewindowoftheNINDSstudywithinwhichthrombolysisisrecommended
Metaanalysissuggestedstrongevidenceofbenefitupto3h,andguidelinesnowsupportuseofthrombolysisup
to4.5haftertheonsetofsymptoms
Additionally,earlyanticoagulationwithheparinhasbeenshowntoincreasetheriskofintracerebralhaemorrhage,
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withouthavingasignificantimpactontheriskoflongtermdisabilityordeath
Assuch,commencementofaspirinisthemostappropriateoption,withanticoagulationatalaterstage
A(somewhatarbitrary)delayof2weeksafteracutestrokeisrecommendedbeforestartingwarfarinforAF,to
minimisetheriskofhaemorrhagiccomplications
20455
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Question25of295
YouarecalledtoseeamanwhoisdueforelectiverighthemicolectomyforaDukeBcoloniccarcinoma.Hisadmission
ECGshowsatrioventriculardissociationwithaventricularresponseof45bpm.Heistotallyasymptomatic.
Whichoneofthefollowingisthemostappropriatepieceofadvice?
A Donothingandlettheoperationgoaheadasplannedtomorrow
B Insertatemporarypacemakerbeforetheoperation
C Performanexercisetestbeforetheoperation
D Postponetheoperationandreferforanoutpatientpermanentpacemaker
E Startaninfusionofisoprenalineanhourbeforetheoperation
Explanation
TheanswerisInsertatemporarypacemakerbeforetheoperation
Pacing
Casenotes
Atrioventriculardissociationisanalternativedescriptionforcompleteheartblock.Performingalargeoperation
duringcompleteheartblockriskshaemodynamiccompromise.Althoughheisnotsymptomaticandisnot
profoundlybradycardicatpresent,vagaltonecanincreaseintraoperatively,whichmaycompromisehiscardiac
output.Itwouldbeappropriatetoplaceatemporarypacingwire(ideallyviathejugularapproach).Therefore
insertionofatemporarypacemakerbeforetheoperationisthebestanswerhere.
Temporarypacing
Indicationsfortemporarypacinginclude:
symptomaticbradycardiathatisnotimprovedbyatropine
completeheartblockcausingoratriskofhaemodynamiccompromise
suppressionoftachyarrhythmiasthatarenotamenabletodrugtherapy(toenableoverdrivepacing).
Permanentpacing
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Permanentpacingisrequiredfor:
completeheartblock
drugresistanttachyarrhythmias
MobitztypeIIheartblock
persistentAVconductionblockpostMI
sicksinussyndrome.
Patientswithtrifascicularblockshouldbeconsideredforpermanentpacingifthereisevidenceof:
syncope
othercardiacsymptomsattributabletoAVblock
evidenceofcompleteheartblock.
Donothingandlettheoperationgoaheadasplannedtomorrow(OptionA)isincorrect.Asdescribedvagaltonecan
increaseintraoperativelywhichmaycompromisehiscardiacoutputrulingthisoptionoutasthebestanswer.
Performanexercisetestbeforetheoperation(OptionC)isincorrect.Anexercisetestwouldbeunhelpfulinthissetting.
Postponetheoperationandreferforanoutpatientpermanentpacemaker(OptionD)isincorrect.ADukeBcarcinomahas
extendedthroughthebowelwall,makingaquickoperationnecessary.Delayingtheoperationforanoutpatientreferralis
inappropriate.
Startaninfusionofisoprenalineanhourbeforetheoperation(OptionE)isincorrect.Isoprenalinecanbeusedasan
adjuncttoincreaseheartrateinbradycardicpatientsbutwouldusediftemporarypacingwasnotavailable.
42029
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Question26of295
Aneonateisnotedtobecyanosedwithinthe24hfollowingdelivery.
Whichcardiacabnormalitywouldbethemostlikelycause?
A Ebsteinsanomaly
B Eisenmengerventricularseptaldefect
C Hypoplasticleftheart
D TetralogyofFallot
E Transpositionofthegreatvessels
Explanation
TheanswerisTranspositionofthegreatvessels
Transpositionofthegreatarteriesismorelikelytopresentearlywithcyanosisasthereisalmostcompleteseparation
ofthesystemicandpulmonarycirculationsastheductusarteriosusbeginstocloseafterdelivery,cyanosiswillstart
tomanifestearly.Therefore,thebestanswerhere.
Cyanosisinneonates
Thecyanoticheartconditionsare:
Hypoplasticleftheartsyndrome:aconditioninwhichtheleftheartisunderdeveloped.Bloodmustpass
fromtheleftatriumthroughanASDintotherightatriumandthenontotherightventricleitthenshunts
throughtotheaortaviaapatentductusarteriosus.
TetralogyofFallot:aconditioninwhichthepulmonaryvalveoroutflowtractisobstructed(eitherstenosed,
underdevelopedorblockedbyovergrowthofheartmuscle).ThereisaVSDwithanaortathatsitsabovethe
VSD(knownasanoverridingaorta).Therightventricleistypicallyhypertrophied(developingaboot
shapedappearanceonthechestXray)
Transpositionofthegreatvessels:aconditioninwhichtheanatomicalrightventricleisconnectedtothe
aortatheanatomicalleftventricleisconnectedtothepulmonaryartery.APFO,ASD,VSDorductus
arteriosusmustbepresentforthechildtosurviveotherwisetherewouldbenowayforoxygenatedbloodto
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enterthesystemiccirculation.
Ebsteinsanomaly:aconditioninwhichthetricuspidvalveinsertionpointisabnormallylow,creatinga
smallrightventricleandalargerightatrium.Thetricuspidvalveisabnormal,allowingregurgitationand
elevationofrightatrialpressuresthisdeoxygenatedbloodthenshuntsacrossanASDintotheleftsystem
causingcyanosis.
Totalanomalouspulmonaryvenousconnection:aconditioninwhichallfourpulmonaryveins(whichcarry
oxygenatedbloodnormallytothelefthearttopump)drainintosystemicveins(suchastheSVC)orintothe
rightatrium.Therefore,oxygenatedbloodmixeswithvenousbloodintherightatrium.
Inallthecyanoticheartconditions,forthechildtosurvive,theremustbeashuntofsomekindleadingto
mixingofblood.
Ebsteinsanomaly(OptionA)isincorrect.Thiswouldnotbethemostlikelycauseofthedescribedpresentation.
Eisenmengerventricularseptaldefect(OptionB)isincorrect.EisenmengerVSDissomethingthattakesmanyyearsto
developthisoccursinuntreatedVSDswithasignificantlefttorightshunt.Overtimethepulmonarycirculationbecomes
hypertrophiedinresponsetothehighpressurestransmittedfromtheleftventricle.Thisresultsinlungarterialpressures
becomingelevatedanddevelopingpulmonaryhypertensionwhenthesepressuresexceedleftventricularpressures,there
willberighttoleftshuntingcausingcyanosis.Thistakesmanyyearstodeveloptherefore,isnotthecorrectchoicehere.
Hypoplasticleftheart(OptionC)isincorrect.Thiswouldnotbethemostlikelycauseofthedescribedpresentation.
TetralogyofFallot(OptionD)isincorrect.AlthoughtetralogyofFallotismuchmorecommonthantransposition,the
rightventricularoutflowtractgradient,whichisthemajordeterminantofcyanosisinFallots,doesnotbecomemaximal
until69monthsafterbirth.ManybabieswithFallotsare,therefore,pinkatbirthbutgraduallybecomecyanosedover
thefirstfewmonthsoflife.Therefore,notthecorrectanswer.
41981
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Question27of295
A34yearoldprofessionalfootballerisevaluatedforsymptomsofdizzinessduringexercise.Physicalexamination
revealsalaterallydisplacedapicalimpulse.Onauscultation,thereisa2/6midsystolicmurmurintheaorticareathat
increasesonsuddenstanding.TheECGshowsLVHandQwavesintheV2V5leads.
Whatisthemostlikelydiagnosis?
A Youngonsethypertension
B AcuteMI
C Aorticstenosis
D Hypertrophiccardiomyopathy
E Atrialseptaldefect
Explanation
TheanswerisHypertrophiccardiomyopathy(HCM)
Inthiscase,weshouldconsiderthecausesofamidsystolicmurmurintheaorticareainayoungpatient.Thisisthe
correctanswerbecausethefeaturesareallconsistentwithhypertrophiccardiomyopathy.Patientsclassicallyhavea
systolicmurmurthatbecomesworseonstandingandbecomesquieteronsquatting.Patientstypicallycomplainof
dizzinessonexertionandhavedisplacedandforcefulapex.ECGsinHCMtypicallyhaveLVH.OtherECGchanges
cangivetheappearancesofischaemiadespitenormalcoronaryarteriesdeepTwaveinversionoranteriorQwaves
arecommon.
Hypertrophicobstructivecardiomyopathy
Adverseeffects
Hypertrophiccardiomyopathyisthesinglemostcommoncauseofsuddendeathinyoungathletes
Syncopeandsuddendeathareassociatedwithsevereexertionandcompetitivesports,whichshouldbe
avoidedinpatientswithhypertrophiccardiomyopathy
Symptoms
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Themajorityofpatientsareasymptomaticoronlymildlysymptomatic
Themostcommonsymptomisdyspnea
Examinationandinvestigationfindings
Typicalexaminationfindingsinclude
leftventricularhypertrophy
aloudS4
forcefulatrialsystolecausingadoubleapicalimpulse
apossibletripleapicalimpulseduetoalatesystolicbulge
thecarotidpulsedemonstratesalatesystolicpulsecausingthecharacteristicjerkyfeature
Incontrasttoaorticstenosis,thesystolicmurmurofhypertrophiccardiomyopathy
doesnotradiatetothecarotids
decreasesonsquattingandpassivelegelevationandincreaseswiththeValsalvamanoeuvre
ECG
ThemostcommonchangesseenontheECGareSTTwaveabnormalitiesfollowedbyleftventricularhypertrophy
QwavesmayalsooccurinleadsII,III,aVForV2V6
TheexactcauseoftheQwavesremainsunclear
Youngonsethypertension(OptionA)isincorrect.Thegivenfindingsdonotsupportthisasthemostlikelydiagnosis.
AcuteMI(OptionB)isincorrect.AcuteMIisunlikelybecausethepatientisyoungandhasnotcomplainedofchestpain.
Aorticstenosis(OptionC)isincorrect.Aorticstenosiscausesanejectionsystolicmurmurandisunlikelyina34yearold
patientittypicallymanifestsinthe6070s.Evenpatientswithabicuspidvalverelatedaorticstenosisareintheir50s.
Atrialseptaldefect(OptionE)isincorrect.Atrialseptaldefectsaretypicallyassociatedwithrightbundlebranchblock.
Patientshaveafixedsplitsecondheartsound.Iftheshuntissignificant,theremaybeamiddiastolicflowmurmurover
thetricuspidarea.
41885
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Question28of295
A62yearoldpatientpresentswithatrialfibrillationofunknownduration.
Whichdrugmayslowhisventricularrateoveraprolongedperiodbutisunlikelytoresultincardioversion?
A Adenosine
B Amlodipine
C Digoxin
D Flecanide
E Amiodarone
Explanation
Digoxin
DigoxinhasinotropicactionsbasedoninhibitionofcardiacNa+/K+ATPase
Theantiarrhythmicactivityappearstobemediatedpredominantlythroughvagalstimulation
Digoxinisusedtoslowventricularrateinatrialfibrillation
Adenosinewillrevealunderlyingtachycardiabutisunlikelytoresultincardioversionversusflecainide
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Question29of295
A55yearoldmanhasinfectiveendocarditis.Hehasrefuseddentalworkforanumberofyearsandpresentedwithnight
sweatsandlethargytohisGP.SubsequentbloodculturesdemonstratedaS.viridansbacteraemia.Onexaminationheis
pyrexial,37.8oC,hisBPis110/70mmHg,pulseis95bpm.Hehassplinterhaemorrhagesonexaminationofhisfingers.
Auscultationrevealsamurmurconsistentwithmitralregurgitation.Hischestisclear.Thetablebelowcontains
investigationresults.
Hb 10.7g/dl
WCC 13.1109/litre
PLT 211109/litre
Na+ 139mmol/litre
K+ 4.9mmol/litre
Creatinine 139mol/litre
ESR 72mm/h
ECGonadmission PRinterval180ms,otherwisenosignificantchanges
Echocardiogram mitralregurgitationwithevidenceofvegetations
Whichoneofthefollowingwouldbeconsideredanurgentindicationforsurgicalinterventionafter12daysofantibiotic
therapy?
A IncreasingPRinterval
B Systolicmurmurafter10daysofantibiotics
C Increasingfever
D RaisedESR
E Mobilevegetation>15mminsize
Explanation
Surgicalinterventionpostinfection
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Surgicalinterventionpostinfection
Endocarditis
IncreaseofthePRintervalsuggestsextensionoftheendocarditicinfectionintothemyocardium
Thisalsoraisesthepossibilityofabscessformation,particularlygiventhelengthoftimeofantibiotictreatmentso
far,assuchurgentsurgicalreferralisindicated
Ruptureintothepericardiumisanindicationforsamedaysurgicalintervention
Delahayeetal.,(2004)Heart,90:618620
Otherindications
Otherindicationsforurgentsurgicalinterventioninclude
mitralregurgitationoraorticregurgitationwithheartfailure
septalperforation
valvularobstruction
Particularlylargevegetations,(>15mm)arealsoanindicationforsurgicalassessment,(althoughnotnecessarily
forurgentintervention)
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Question30of295
Youreviewa26yearoldwomanwhoattendsthecardiologyclinicwithherhusband.Theywishtostartafamily,butthey
havebeenreferredbytheirGP,asheisworriedthatthewomanhasahistoryofheartdisease.Whichoneofthefollowing
cardiovascularconditionsisanabsolutecontraindicationtopregnancy?
A Mitralvalveprolapse
B Previousrepairedpatentductusarteriosus
C Atrialseptaldefect
D Primarypulmonaryhypertension
E Bicuspidaorticvalve
Explanation
Pregnancy
Contraindications
Althoughincreasedmonitoringisrecommendedinpatientswithmitralvalveprolapseorcongenitalbicuspid
aorticvalve,neitherareabsolutecontraindicationstopregnancy
Smallatrialseptaldefectsoftenremainundetectedformanyyears,andpreviouslyrepairedpatentductusarteriosis
shouldnotimpairpregnancy
Primarypulmonaryhypertensionrapidlyworsensinpregnancy,however,andpatientsareadvisednottoget
pregnant
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Question31of295
Normalpregnancyisassociatedwithwhichoneofthefollowinghaemodynamicchanges?
A A20%reductioninbloodvolumeandcardiacoutput
B A10mmHgdropindiastolicbloodpressureduringthesecondtrimester
C Bradycardiawitharadialpulseratebetween45and55beatsperminute
D Grade2/6diastolicmurmuratthemitralarea
E Pulsusalternans
Explanation
Haemodynamicchangesinpregnancy
Despiteanexpansionoftheplasmavolumeandcardiacoutputof50%,meananddiastolicbloodpressuresfallby
approximately15%owingtoareductioninperipheralvascularresistance
Thereislittlechangeinsystolicbloodpressure,butdiastolicpressureisreduced(510mmHg)fromabout1216
weeks
Diastolicpressureusuallyincreasesthereaftertoprepregnancylevelsbyabout36weeks
Tachycardiaratherthanbradycardiaisarecognisedphysiologicalchangeduringpregnancyasaconsequenceof
reducedperipheralvascularresistanceandfallinbloodpressurelevels
Theheartmaybeslightlyenlargedandmaybedisplacedoutwardbecauseofthehighdiaphragm
Apulmonarysystolicmurmurfromahighbloodflowiscommonandtheremaybeaphysiologicalthirdheart
sound
Diastolicmurmursaregenerallypathologicalandatthemitralareamaysignifymitralstenosis
Thepresenceofpulsusalternansusuallysignifiesadvancedheartfailure
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Question32of295
AyoungmancomestotheEmergencyDepartmentcomplainingoffeelingunwellandpalpitations.Supraventricular
tachycardiaisconfirmedonECGandherespondstocarotidsinusmassage.Subsequently,theECGshowsaPRinterval
of0.09s,widenedQRScomplexinallleadswithaslurredupstroke,dominantRwaveinV1andleftaxisdeviation.
Whatisthemostlikelydiagnosis?
A Rheumaticfever
B WolffParkinsonWhitesyndrome
C Atrialfibrillation
D ASD
E Rightbundlebranchblock
Explanation
TheanswerisWolffParkinsonWhitesyndrome
Diagnosisandtreatment
WolffParkinsonWhitesyndromeisclassicallyassociatedwithashortPRinterval(<0.12s).
SlurringoftheQRScomplexisowingtoanextrawavecalledadeltawave.
AstheAVnodeandbypasstracthavedifferentconductionspeedsandrefractoryperiods,areentrycircuitcan
develop,causingparoxysmsoftachycardia.
Carotidsinusmassageorintravenousadenosinewilloftenterminateanepisodeofthisformoftachycardia.
Rheumaticfever(OptionA)isincorrect.Thesefeaturesarenottypicalmyocarditis,andoneofthefeaturesofmyocarditis
duetorheumaticfeverisaprolongedPRinterval.
Atrialfibrillation(OptionC)isincorrect.ThepresenceofPwaves(asaPRintervalisprovided)rulesoutatrial
fibrillation.
ASD(OptionD)isincorrect.AnASDisassociatedwithaRBBB(rSR)pattern,butagainthedescriptionistypicalfor
WPW.
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Rightbundlebranchblock(OptionE)isincorrect.AnASDisassociatedwithaRBBB(rSR)pattern,butagainthe
descriptionistypicalforWPW.
41906
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Question33of295
An18yearoldmanwithMarfansyndromeisreviewedinthecardiologyclinic,afterascreeningECGisfoundtobe
abnormal,withleftaxisdeviationandprominentQwavesinI,III,aVFandV3V6.
Whichcardiacabnormalityismostlikelytobefound?
A Aorticregurgitation
B Atrialseptaldefect
C Dilatedcardiomyopathy
D Pulmonaryregurgitation
E Persistentductusarteriosus
Explanation
AorticregurgitationandMarfansyndrome
Marfansyndromeischaracteristicallyassociatedwithprogressiveaorticrootdilatationleadingtoaortic
regurgitationandanincreasedriskofdissection
Otherskeletalmanifestationsinclude
tallstature
scoliosis
chestwallmalformations
higharchedpalate
lensdislocation
Mitralvalveprolapseisalsocommonbutthereisnoassociationwithothercongenitalmalformationsor
cardiomyopathy
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Question34of295
A73yearoldwomanisadmittedforpacemakerinsertionbecauseofanumberofsyncopesandperiodsofcompleteheart
blockidentifiedon72hourECG.ShereceivesaDDDRpacemaker.WhatdoestheRstandfor?
A Ratelimiting
B Ratemodulated
C Repolarising
D Rateenhancing
E Ratereducing
Explanation
DDDRpacemakers
DDDRstandsfordualchamberpaced,dualchambersensed,dualresponse,ratemodulateddevice
Inotherwords,theactivityofthepacemakerisvariedaccordingtothebackgroundheartrate
Dualchamberpacingdevicesarelesslikelythanventricularpacingonlydevicestoleadtopacemakersyndrome
inthecontextofatrialfibrillation,whichareassociatedwithincreasedriskofatrioventriculardysyncrony
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Question35of295
A70yearoldmanpresentswithseveretearingbackandchestpainwhichcameonverysuddenly.Hehasapastmedical
historyofhypertensionforwhichhetakesramipril10mgdaily,amlodipine5mg,andhesmokes30cigarettesperday.
Onexaminationheisinseverepain,hisBPis155/85mmHg,hehasbilateralupgoingplantarsand4/5weaknessaffecting
leftankledorsiflexion.Heappearstohaveapericardialrub.Whichoneofthefollowingfeaturesismostsuggestiveof
dissectingaorticaneurysm?
A Thepatternofpaindescribed
B Hypertension
C Bilateralupgoingplantars
D Leftlowerlimbsigns
E Pericardialrub
Explanation
Diagnosingdissectingaorticaneurysm
Theacuteonsetofseveretearingbackandchestpainisverytypicalofdissectingaorticaneurysm
Itisimpossibletotellwhetherhisneurologicalsignsseenareneworold,andapericardialruborhypertensionare
morelikelytobeassociatedwithothercausesofchestpain
Painlessaorticdissectiononlyoccursinaround10%ofpatients,andismorecommoninpatientswhohave
connectivetissuedisorderssuchasMarfansyndrome
Othernotes
Upperlimbneurologicalsignsaremorelikelytobeassociatedwiththoracicaorticdissection,lowerlimbsigns
maybecommonerinanteriorspinalarterydissectionorthrombosis
20920
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Question36of295
An81yearoldmalepatientattendsthecardiologyclinicforhissymptomsoffatigueandankleoedema.Twodimensional
echocardiographyshowssignificantventricularwallthickeningandmarkeddilatationofbothatria.Theleftventricular
myocardiumhasagranularsparklingappearance.Heisreferredforholtermonitoringandtoldhewillhavepredominantly
symptomatictreatment.
Whichoneofthefollowingconditionsishemostlikelytohave?
A Amyloidheartdisease
B Constrictivepericarditis
C Dilatedcardiomyopathy
D Hypertrophiccardiomyopathy
E Ischaemiccardiomyopathy
Explanation
TheanswerisAmyloidheartdisease
Thisgentlemanhascardiacamyloid,characterisedbyheartfailurewitharestrictivefillingpattern(demonstratedby
theenlargedatria).Theventriclesareoftenthickandappearhypertrophied,butinfacthavepoorsystolicand
diastolicfunction.Thespeckledappearanceisverycharacteristicofamyloidbutcannotbeusedalonetodiagnoseit.
Youreachtheconclusionthatthisisamyloidbecausetheechofindingsarenotconsistentwiththeotheranswers.
Theechocardiographicappearancesdohelpexcludetheotherconditions.
Inthescenarioaholtertesthasbeenordered.Thiscouldpointtoamyloidinwhichbradycardiawith2:1or
completeheartblockiscommon.However,equally,HCMsalsohaveepisodesofVT,whichholtermonitoringis
appropriatetodiagnose.
Constrictivepericarditis(OptionB)isincorrect.Constrictivepericariditstypicallyhasapparentlynormalleftsystolic
ventricularfunctionbutdiastolicfillingcanbeimpairedtheventricularfillingisdependentoneachotherandthereis
oftenseptalbounceseenonechotheseptumappearstobounceintotheLVastheRVfills.
Dilatedcardiomyopathy(OptionC)isincorrect.Dilatedcardiomyopathywillhavegloballyenlargedventricular
dimensionswithimpairedventricularcontraction.
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Hypertrophiccardiomyopathy(OptionD)isincorrect.Hypertrophiccardiomyopathy(HCM)(answerA)hasassymetical
leftventricularhypertrophythisparticularlyinvolvestheseptumcausingoutflowtractobstructionotherfindingsin
HCMincludesystolicanteriormotionofthemitralleaflets(SAM).
Ischaemiccardiomyopathy(OptionE)isincorrect.Ischaemiccardiomyopathyresultsfromlongtermuntreatedischaemia
andhasdilatedventricleswithpoorfunctionandoftenregionalwallmotionabnormalitiestheischaemicareascontract
moreslowlyandlesswellthantheothers.Theremayalsobescarredandthinsegmentswhereinfarctionhasoccurred
previously.
41980
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Question37of295
A60yearoldmanunderwentacoronaryangiogramforunstableangina.Thenextdaywhilerecoveringinhospitalhe
complainsofseverepaininhisrightfootandpartiallossofsightinthelefteye.Onexaminationthelowerlimbperipheral
pulsesarepresentandofgoodvolume.Thereisgangreneofthelateraltwotoesontherightfoot.Fundoscopyreveals
cholesterolemboliinabranchofthecentralretinalarteryinthelefteye.
Whichoneofthefollowingisthemostprobablediagnosisinthiscase?
A Atheroembolicdisease
B Polyarteritisnodosa
C Buergersdisease
D Arterialthromboembolism
E Disseminatedintravascularcoagulopathy
Explanation
Artheroembolicdisease
Althougheachofthementionedoptionsisavalidpossibleunderlyingcausebehindthispresentation,itisclear
thatthepictureismoretypicalofatheroembolicdisease
Itisduetocholesterolembolilodgedinperipheralarteries,commonlyasaresultofangiographicorothersurgical
vascularprocedures
Clinicalfeatures
Clearlytheclinicalfeatureswilldependonthesiteofembolisation
Themostcommonclinicalfindingsarecutaneousfeatures,renalfailureandworseninghypertension
Thepresenceoffootpulseswithgangrenoustoesshouldsuggestcholesterolembolisation
Theretinaprovidesauniqueopportunitytovisualisethecholesterolemboli
Renalfailuremaymanifestasgradualdeteriorationofrenalfunctionfollowingangiographyormaybeacute(this
maymimicacutedissectionoftherenalarteryduringrenalangiography)
Eosinophilia,eosinophiluria,araisedESRandhypocomplementinaemiahavebeenfoundinatheroembolicdisease
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Arterialthromboembolismisrelatedtodistalembolisationofproximal,preexistingatheroma
1584
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Question38of295
A36yearoldwomanpresentswithatransientlefthemiparesisfollowingtreatmentforaleftcalfdeepvenous
thrombosis.Cardiovascularexaminationisnormal.
Whichoneofthefollowingisthemostlikelypredisposingcardiacabnormality?
A EisenmengerASD
B OstiumprimumASD
C OstiumsecundumASD
D Partialanomalouspulmonaryvenousdrainage
E Patentforamenovale
Explanation
TheanswerisPatentforamenovale
PatentforamenovaleTheclinicalscenariodescribesaparadoxicalembolusthatisonethattravelledfromthe
venoussystemintothearterialcirculation.Forthistooccur,theremustbeashuntofsomekind.Patentforamen
ovale(PFO)isthecorrectanswer.
Toanswerthisquestion,youshouldbeawarethatPFOsareverycommonandthisconditionismuchmore
commonthantheotherconditionslisted.EstimatessuggestoneinfourpeoplehaveaPFOpresent.Theshunt
isnotopenthemajorityofthetimeitismerelyapotentialspace.Whenrightatrialpressureexceedsleft
atrialpressure,itwillopenandallowvenousdebristoenterthearterialcirculation.Thisistypicallyduring
valsalvasuchasstrainingatstool,childbirthandduringdiving.
YoushouldalsobeawarethatPFOhasnofindingsonroutineclinicalexaminationasisthecaseinthe
patientinthequestion.Incontrast,alltheotherpotentialoptionsoftenhaveclinicalfindings.
PFOsrequirevalsalvaduringanechocardiographicexaminationwithagigtatedsalinetobestvisualisethem
oncethesalineisgivenintoavein,bubblescanbeseenfillingtherightatrium.Valsalvawillcausethe
PFOtoopenand(evenifthatcannotbeseen)bubblesmaybeseenenteringtheleftatrium.
Partialanomalouspulmonaryvenousdrainagemeansthatbetweenoneandthreepulmonaryveinsopeninto
therightatriumratherthantheleftatriumthereisnoincreasedriskofrighttoleftshunting.Instead,these
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patientsmaybecyanosedandclubbed.
InASD,whetherprimum(lesscommon)orsecundum(morecommon),patientswillhavefixedsplittingof
thesecondheartsound,mayhaveanejectionsystolicmurmurofincreasedbloodflowacrossthepulmonary
valveandwillhaverightbundlebranchblock(RBBB)onECG.
PatientswithEisenmengersyndromehavehadlongstandingshuntingfromthelefttotherightcirculation,
leadingtoanincreaseinpulmonarypressureswitharterialhypertrophythereisthenreversaloftheshunt,so
itbecomesrighttoleft.Thesepatientswillhavecyanosisandclubbing.
EisenmengerASD(OptionA)isincorrect.ItwouldbeunusualforEisenmengerASDtopresentwithnoclinicalfindings.
OstiumprimumASD(OptionB)isincorrect.ItwouldbeunusualforostiumprimumASDtopresentwithnoclinical
findings.
OstiumsecundumASD(OptionC)isincorrect.ItwouldbeunusualforostiumsecundumASDtopresentwithnoclinical
findings.
Partialanomalouspulmonaryvenousdrainage(OptionD)isincorrect.Itwouldbeunusualforpartialanomalous
pulmonaryvenousdrainagetopresentwithnoclinicalfindings.
42026
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Question39of295
A62yearoldmanisreviewedthedayafteradmissionwithannonSTelevationmyocardialinfarction(NSTEMI).Hehas
ahistoryofsmoking,hypertensionanddiabetesmellitus,andsufferedapreviousanteriorNSTEMI1yearearlier.Onthis
occasionhehasinferiorTwaveinversionandhistroponinroseto5.2(significantlyelevated)atthe12hrspoint.His6
monthsCVriskisassessedat4.5%.
Whichofthefollowingisthemostappropriatenextstepwithrespecttoinvestigations?
A Angiographywithin96hrs
B Angiographywithin6weeks
C Exercisetest
D Nofurtherinvestigationsneededatthisstage
E Stressecho
Explanation
TheanswerisAngiographywithin96hrs
NICEguidanceisveryclearinthismatter.
"Offercoronaryangiography(withfollowonPCIifindicated)within96hoursoffirstadmissiontohospitaltopatients
whohaveanintermediateorhigherriskofadversecardiovascularevents(predicted6monthmortalityabove3.0%)if
theyhavenocontraindicationstoangiography(suchasactivebleedingorcomorbidity).Performangiographyassoonas
possibleforpatientswhoareclinicallyunstableorathighischaemicrisk."
Patientswhohavea6monthriskbelow3%aresuitableforconservativemanagement.Exercisetestingandstress
echocardiographyarebestreservedwherethediagnosisofischaemiarelatedchestpainisindoubt.
http://www.nice.org.uk/guidance/cg94/chapter/1Guidance#assessmentofapatientsriskoffutureadverse
cardiovascularevents(http://www.nice.org.uk/guidance/cg94/chapter/1Guidance#assessmentofapatientsriskof
futureadversecardiovascularevents)
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Question40of295
Whichoneofthefollowingbestdescribesthemechanismofactionofflecainideasanantiarrhythmicagent?
A Slowstheupstrokeoftheactionpotential
B Increasestheactionpotentialduration
C Hasadirectmembraneeffect
D Increasesvagaltone
E AffectsSAandAVnodes
Explanation
TheanswerisSlowstheupstrokeoftheactionpotential
FlecainideisaclassIcagentthatworkspredominantlybyslowingtheupstrokeoftheactionpotentialhowever,it
doesnotaltertheoveralllengthoftheactionpotentialduration.
Inotherwords,itcausesamarkeddecreaseinconductivity,withlittleeffectonrefractoriness.
ItisusefulinpreventingoccurrencesofpAFandtreatingrecurrentSVT.
Increasestheactionpotentialduration(OptionB)isincorrect.Asdescribedflecainidedoesnotaltertheoveralllengthof
theactionpotentialduration.
Hasadirectmembraneeffect(OptionC)isincorrect.Calciumchannelblockershaveadirectmembraneeffect.
Increasesvagaltone(OptionD)isincorrect.ClassVagents(digitalisagents)affectSAandAVnodesbyincreasingvagal
tone.
AffectsSAandAVnodes(OptionE)isincorrect.Calciumchannelblockersmainlyaffectthesinoatrialand
atrioventricularnodes.
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Question41of295
A40yearoldwomanhasamoderateVSD.
Beforeundergoingwhichofthefollowingprocedureswillsheneedantibioticprophylaxis?
A Permanentpacemakerinsertion
B Bronchoscopywithrigidbronchoscope
C Endotrachealtubeinsertion
D Removalofintrauterinedevice
E UpperGIendoscopy
Explanation
TheanswerisPermanentpacemakerinsertion
NICEguidancefortheuseofantibioticprophylaxischangedin2008.Priortothis,patientsatriskofendocarditis
weregivenantibioticspriortoawidevarietyofprocedures,includingdentalworkandbronchoscopy.
Inthe2008guidance,peoplewiththefollowingconditionswereidentifiedasbeingathighriskofendocarditis:
acquiredvalvularheartdiseasewithstenosisorregurgitation
valvereplacement
structuralcongenitalheartdisease,includingsurgicallycorrectedorpalliatedstructuralconditions,butexcluding
isolatedatrialseptaldefect,fullyrepairedventricularseptaldefectorfullyrepairedpatentductusarteriosus,and
closuredevicesthatarejudgedtobeendothelialised
previousinfectiveendocarditis
hypertrophiccardiomyopathy.
Routineantibioticprophylaxiswasnolongerrecommendedfor
dentalprocedures
proceduresinvolving:
upperandlowerGItract
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genitourinarytractincludingurological,gynaecologicalandobstretricprocedures
childbirth
upperandlowerrespiratorytractincludingENTproceduresandbronchoscopy.
OtherproceduresarenotcoveredbytheNICEguidelines.Itiscommonpracticetouseantibioticcoverduring
permanentpacemakerinsertionandthisistrueforallpatientsnotjustthosewithVSD.
ItisimportanttonotethattheNICEguidanceonthisissueiscontroversial.Recentdatasuggesttheremayhavebeen
anincreaseinendocarditiscasesfollowingtheguidelines.Theyarecurrentlyunderreviewandmaychange.
Bronchoscopywithrigidbronchoscope(OptionB)isincorrect.Routineantibioticprophylaxisisnolongerrecommended
forGItractprocedures.
Endotrachealtubeinsertion(OptionC)isincorrect.Routineantibioticprophylaxisisnolongerrecommendedfor
respiratorytractprocedures.
Removalofintrauterinedevice(OptionD)isincorrect.Routineantibioticprophylaxisisnolongerrecommendedfor
genitourinarytractprocedures.
UpperGIendoscopy(OptionE)isincorrect.RoutineantibioticprophylaxisisnolongerrecommendedforGItract
procedures.
41926
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Question42of295
Apatientwithamechanicalaorticvalvereplacementinserted5yearsagopresents48hoursafterdevelopingaright
hemiparesis.CTscanshowscerebralinfarction.Thereisnoevidenceofcerebralhaemorrhage.TheINRis3.0.
Howwouldyoumanagethiscase?
A ReversetheanticoagulationwithvitaminK
B Stopwarfarinandstartintravenousunfractionatedheparin
C Increasethedoseofwarfarin
D Continuetherapeuticwarfarin
E DecreasethedoseofwarfarinuntiltheINRis1.5
Explanation
TheanswerisContinuetherapeuticwafarin
Thepatienthaspresentedtoolatetoconsiderthrombolysis.Asthereisnoevidenceofhaemorrhagictransformation,
andtheriskdiminisheswithtime,therapeuticwarfarinshouldbecontinued.
ReversetheanticoagulationwithvitaminK(OptionA)isincorrect.Reversingtheanticoagulationwithoutreplacement
wouldputthepatientatdramaticallyhighriskoffurtherembolicstroke.
Stopwarfarinandstartintravenousunfractionatedheparin(OptionB)isincorrect.Traditionally,suchacutestrokemay
havebeenswitchedtoIVunfractionatedheparinduetothefearthatifableedoccurredheparinwouldbeeasiertoreverse.
However,astheriskoftransformationinthispatientisnowlow(itisalready48hourssincetheeventhappened),the
associateddifficultiesinmanagingIVheparin(oftenoverorundertherapeutic),andtheabilitynowtorapidlyreverse
warfarinwithprothrombincomplexconcentratemakesthisalessgoodanswer.
Increasethedoseofwarfarin(OptionC)isincorrect.ThetherapeuticINRrangeformechanicalaorticvalvesisbetween
2.5and3.5(henceoptionCisincorrect).
DecreasethedoseofwarfarinuntiltheINRis1.5(OptionE)isincorrect.AlowerINRwillexposethepatienttotherisk
ofvalveassociatedthrombosisandthromboembolism.
41970
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Question43of295
A62yearoldwomanwithapasthistoryofrheumaticfeverpresentsforreview.Inrecentyearsshehasbeenwell,butshe
underwentadentalextractionsome8weeksago.Duringthepast4weeksshehassufferedintermittentfevers,chillsand
nightsweats.Onexaminationthereisapansystolicmurmur,loudestattheapex.Bloodtestsrevealanormochromic,
normocyticanaemiaandraisedESR.
Whichorganismismostlikelytoberesponsibleforthisclinicalpicture?
A Candidaalbicans
B Enterococci
C Staphylococcusaureus
D Staphylococcusepidermidis
E Viridansstreptococci
Explanation
TheanswerisViridansstreptococci
Subacutebacterialendocarditis
Thispatienthaspreviousrheumaticfever,whichsuggestsshemayhaveastructurallyabnormalvalvethis
wouldmakeherpronetoendocarditis.Inthepast,shewouldhavereceivedroutineantibioticprophylaxis
priortodentalextractionhowever,theNICEguidancepresentlysuggestsnoneisrequired.
Fromherpresentationitismostlikelythatshenowhassubacutebacterialendocarditis.
Organismsassociatedwithsubacutebacterialendocarditisincludeviridansstreptococci,Streptococcusbovis,
enterococciandStaphylococcusaureus.
InfectionsoriginatingfromthemoutharealmostallstreptococciincudingStreptococcusviridansandS.
mutans.
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Enterococci 1015%
Other 2025%
Coagulasenegative 13%
Signsandsymptomsofendocarditis
Patientsmaypresentwithfever,chillsorfatigue(saidtooccurin2580%ofpatients).
Heartmurmursmaybeabsentinrightsidedendocarditis.Embolicphenomenawithperipheral
manifestationsmaybefoundinupto50%ofpatients.
Othermanifestationsincludefingerclubbing,petechiae,Oslernodes,splinterhaemorrhagesandJaneway
lesions.
Splenomegalymayalsooccurinassociationwithsubacutebacterialendocarditis.
Investigations
Itiscrucialtocollectatleastthreesetsofbloodsamplesforcultureduringthefirst24h,whichshould,if
possible,betakenbeforeantibioticsarestarted.
Normochromic,normocyticanaemiamayalsooccur.
CRPandESRareelevated.
AfalsepositiveVDRL(syphilistest)mayoccur.
Transthoracicechocardiography,withorwithoutadditionaltransoesophagealecho,isindicatedtoconfirm
diagnosis.
Treatment
Prolongedintravenousantibioticsarerequired:IVbenzylpenicillinandgentamicinaretypicalstarting
antibioticsuntilorganismsandsensitivitiesareknown.
Surgerymayberequiredifanabscessdevelops(forexample,inaorticvalveendocarditis).Thiscanbe
challenging,asthereisariskthatthereplacementvalvecanbecomeinfectedandthetiminghastobe
carefullyplanned.
Candidaalbicans(OptionA)isincorrect.Thisisnotthemostlikelyorganisminthisinstance.
Enterococci(OptionB)isincorrect.Thisisnotthemostlikelyorganisminthisinstance.
Staphylococcusaureus(OptionC)isincorrect.Thisisnotthemostlikelyorganisminthisinstance.
Staphylococcusepidermidis(OptionD)isincorrect.Thisisnotthemostlikelyorganisminthisinstance.
42016
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Question44of295
A15yearoldpatientundergoesechocardiography,whichshowsarightsidedaorticarch.
Whichcardiacconditionismostlikely?
A Coarctationoftheaorta
B Ebsteinsanomaly
C Hypoplasticleftventricle
D Noonansyndrome
E TetralogyofFallot
Explanation
TheanswerisTetraologyofFallot
Rightsidedaorticarchesarerarebutdooccurinthosepatientswithcongenitalheartdisease.Theyaremoststrongly
associatedwithtetralogyofFallot.Approximately25%ofpatientswithFallotstetralogyhavearightsidedaortic
arch.
Coarctationoftheaorta(OptionA)isincorrect.Coarctationisstronglyassociatedwithbicuspidaorticvalves(50%of
coarctationshavebicuspidvalvesbutfewofthosewhohavebicuspidvalveshavecoarctation).
Ebsteinsanomaly(OptionB)isincorrect.Ebsteinsanomalyisacongenitalabnormalityofthetricuspidvalvewhichhas
anassociationwithrightsidedaccessorypathwaysbutnotrightsidedaorta.
Hypoplasticleftventricle(OptionC)isincorrect.Inhypoplasticlefthearttheaortaisgrosslyunderdevelopedastheleft
ventricleissmallandunderdeveloped.
Noonansyndrome(OptionD)isincorrect.Noonansyndromeisanautosomaldominantconditionwhichhasphenotypic
featuresofTurnersbutitcanoccurinbothmalesandfemales.Thepulmonaryoutflowtractandvalveareabnormal
(typicallypulmonarystenosis)butnotarightsidedaorticarch.
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Question45of295
A12yearoldboywithknownheartdiseaseisbeingadvisedregardingtherisksofinfectiveendocarditis(IE).
Whichcardiaclesionismostlikelytobepronetoinfection?
A Aorticregurgitation
B Atrialseptaldefect
C Pulmonaryvalveregurgitation
D Tricuspidregurgitation
E Tricuspidstenosis
Explanation
TheanswerisAorticregurgitation
Cardiacinfection
Patientsathighriskofinfective(bacterial)endocarditisincludethosewithprostheticmaterials(valves,
patches,conduitsorshunts),particularlyinthefirst6monthsafterplacement,iebeforethesematerials
becomeendothelialised
Otherriskfactorsincludecomplexcyanoticheartdisease(includingVSD)andpreviousepisode(s)of
endocarditis
Endocarditismorecommonlyaffectstheleft(highpressure)sideoftheheartthantherightthus,tricuspid
regurgitationincorrect.Highpressuresystemscreatemorebloodturbulenceandpermitinoculationofthe
valve.Lesionsaremorelikelytooccuronthelowerpressuresurface.Rightsidedendocarditiswouldbe
morecommoninpatientswhoinjectsubstancessuchasIVDUs
Intermsoffrequency,IEwillmostlikelyaffectthemitralvalve,thenaorticvalve,thenbothaorticandmitral
valves,thentricuspidandfinally(andrarely)thepulmonaryvalve
Ifthevalveisalreadyabnormal,thenthelikelihoodofinfectionisgreaterandwillbemostlikelyonthe
aorticvalve.SinceanswerBistheonlyoptionfeaturingtheaorticvalve,thisismostlikelytobethecorrect
answer.Theotheroptionsaremuchlessfrequentand,therefore,areveryunlikely
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Mitralregurgitationandmitralvalveprolapsewithregurgitationpresentmoderaterisks,whereasmitralvalve
prolapsewithoutregurgitationisalowrisk
Infectiveendocarditisinpuremitralstenosisandatrialseptaldefectisuncommon
PatientsatriskofIEshouldbemadeawareofpresentingsymptomsandcounselledtoseekmedicaladviceif
theybecomeunwell
Ifthediagnosisisconsidered,itisessentialthatrepeatedsetsofbloodculturesareobtainedbeforeantibiotics
arestarted
RecentUKguidelinesnolongersupporttheuseofantibioticprophylaxistopreventendocarditisafterdental
orotherprocedures.However,patientsconsideredathighriskcanstillbeadvisedtoseekantibioticuse
beforeinvasiveprocedures.NICEiscurrentlyreviewingtheseguidelinesandtheymaysoonchange,because
someresearchsuggestsanincreaseinendocarditissinceroutineantibioticprophylaxiswasstopped
https://www.nice.org.uk/guidance/cg64(https://www.nice.org.uk/guidance/cg64)
Atrialseptaldefect(OptionB)isincorrect.Infectiveendocarditisinatrialseptaldefectisuncommon.
Pulmonaryvalveregurgitation(OptionC)isincorrect.Pulmonaryvalveregurgitationismuchlessfrequentandsoless
likelythanpulmonaryvalveregurgitation.
Tricuspidregurgitation(OptionD)isincorrect.Tricuspidregurgitationismuchlessfrequentandsolesslikelythanaortic
regurgitation
Tricuspidstenosis(OptionE)isincorrect.Tricuspidstenosisismuchlessfrequentandsolesslikelythanaortic
regurgitation.
41953
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Question46of295
Inwhichoneofthefollowingscenarioshavestatinsnotbeenshowntobeofbenefit?
A PostMIwithelevatedcholesteroltodecreaseriskofcardiovascularevents
B PostMIwithnormalcholesteroltodecreaseriskofcardiovasculardeath
C PostMIwithnormalcholesteroltodecreaseriskofnonfatalMI
D Primarypreventionwithcholesterol3.9mmol/l
E Primarypreventioninadiabeticmaleaged60withacholesterol6.2mmol/l
Explanation
TheanswerisPrimarypreventionwithcholesterol3.9mmol/l
Statinsandcholesterol
Statinsaredrugsthatcompetitivelyinhibit3hydroxy3methylglutarylcoenzymeAreductase,whichis
involvedincholesterolsynthesis,especiallyintheliver.
Themainroleofstatinsistoreducelowdensitylipoprotein(LDL)andoverallcholesterollevels.
TheyarebetterthanionexchangeresinsatreducingLDL.Theyarelessgoodthanfibratesatreducing
triglyceridesorincreasinghighdensitylipoprotein(HDL)cholesterol.
Statintrials
Therehavebeenseveralimportanttrialswithstatins.
4Sdemonstratedthatforpostmyocardialinfarction(MI)inpatientswithelevatedcholesteroltherewasa
33%reductionincardiovasculareventswithacholesterolreductionof25%.
CAREdemonstrateda24%decreaseincardiovasculardeathandnonfatalMIinpatientswithbothhighand
averagecholesterollevelspostMI.
WOSCOPSdemonstrateda22%reductioninallcausemortalitywithacholesterolreductionof20%in
malesaged4565withcholesterollevelsof>4.0mmol/landthereforedemonstratedthatstatinswereofuse
inprimarypreventionaswellassecondaryprevention.
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Inpatientswithanalreadylowcholesterolandwithoutapreviousevent,therearenodatatosupporttheuse
ofstatinstofurtherreducecardiovascularrisk.ThereforeOptionCisthecorrectanswer.Inalloftheother
scenariosthereisbenefit.
PostMIwithelevatedcholesteroltodecreaseriskofcardiovascularevents(OptionA)isincorrect.Statinshavebeen
showntobeofbenefitinthissituation.
PostMIwithnormalcholesteroltodecreaseriskofcardiovasculardeath(OptionB)isincorrect.Statinshavebeenshown
tobeofbenefitinthissituation.
PostMIwithnormalcholesteroltodecreaseriskofnonfatalMI(OptionC)isincorrect.Statinshavebeenshowntobeof
benefitinthissituation.
Primarypreventioninadiabeticmaleaged60withacholesterol6.2mmol/l(OptionE)isincorrect.Statinshavebeen
showntobeofbenefitinthissituation.
42034
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Question47of295
Youareaskedtoreviewa19yearoldwomanwhopresentswithincreasingshortnessofbreathonexercise.Sheisfroma
travellingfamilyandhasrarelyencounteredmedicalcare.Onexaminationsheappearsofshortstaturewithextraskin
foldsaroundherneck,andappearstohavefailureofsecondarysexualdevelopment.Herbloodpressureisraisedat
165/100mmHg.Shereportsthatherlegsfeeltiredallthetimeandshehasoccasionalchestpainonexercising.
Whichoneofthefollowingcardiacdiagnosesfitsbestwithherclinicalcondition?
A Aorticregurgitation
B Coarctationoftheaorta
C Hypertrophicobstructivecardiomyopathy
D Mitralregurgitation
E Pulmonarystenosis
Explanation
TheanswerisCoarctationoftheaorta
ToanswerthisquestionyoushouldrecognisethatthepatienthasTurnersyndrome(indicatedbythewebbingofthe
neckandlackofsecondarysexualdevelopment)andthatthisisstronglyassociatedwithcoarctationoftheaorta
(indicatedbypainsinlegs,hypertensionandepisodesofchestpain).Inyoungpatientswithhypertension,always
considersecondarycausessuchascoarctation.Theotheroptionsdonotpresentinthismannerandthereforedonot
bestfitthedescription.Turnerpatientsoftenhavebicuspidaorticvalvestheseoccuraspartoftheabnormalaorta
whenthereiscoarctation.
Coarctation
Coarctationisastenosisofvariableseverityintheaortainextremecasestherecanbeadiscontinuityintheaorta.
Bicuspidaorticvalvesarepresentin50%ofpatientswithcoarctation.
Turnersyndromeisstronglyassociatedwithcoarctation.
Infantiletypepresentsearly:stenosisisproximaltotheleftsubclavianarteryhypertensionispresentonlyinthe
rightarm.
Adulttypepresentsinteenstoearlyadulthood:stenosisisdistaltotheleftsubclavianbotharmsare
hypertensivetheupperbodyisbetterdevelopedthanthelower.Legpulsesarediminishedorevenabsent.
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Symptomsinclude:
vigorouspulsationintheneckorthroat
hypertension
tiredlegsorintermittentclaudicationonrunning
leftventricularfailure
anginapectoris
aorticrupture.
Physicalsignstonoteinclude:
radiofemoralpulsedelay
developmentofcollateralvesselsmaybeheardassystolicmurmuroverpraecordium
leftventricularfailure
ejectionsystolicmurmur.
Electrocardiogram(ECG)showsleftventricularhypertrophy,andrightbundlebranchblockiscommon.
Aorticregurgitation(OptionA)isincorrect.Asdescribedaorticregurgitationdoesnotpresentinthismannerandsoisnot
thebestchoicehere.
Hypertrophicobstructivecardiomyopathy(OptionC)isincorrect.Asdescribedhypertrophicobstructivecardiomyopathy
doesnotpresentinthismannerandsoisnotthebestchoicehere.
Mitralregurgitation(OptionD)isincorrect.Asdescribedmitralregurgitationdoesnotpresentinthismannerandsoisnot
thebestchoicehere.
Pulmonarystenosis(OptionE)isincorrect.Asdescribedpulmonarystenosisdoesnotpresentinthismannerandsoisnot
thebestchoicehere.
42020
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Question48of295
An80yearoldmanpresentedtoAccidentandEmergencywithgraduallyincreasingconfusionandshortnessofbreath.
ECGshowed2:1atrioventricularblockwithaventricularrateof40/min.Inordertolocalisethesiteoftheblock,the
physicianmadethepatientdovagalmanoeuvres,duringwhichtherewerenochangesintheblock.Hethengave500mcg
ofatropineandtheconductionratioworsened.
Whereisthelikelysiteoftheconductionblock?
A Atrioventricular(AV)node
B HisPurkinjesystem
C Leftbundlebranch
D Sinoatrial(SA)node
E Unabletocommentfromthedatagiven
Explanation
TheanswerisHisPurkinjesystem
Autonomicmanoeuvres,suchascarotidsinusmassageorValsalva,helptolocalisethesiteofblock.Thisisbecause
theAVnodehasgoodautonomicinnervationandrespondstoincreasesinvagaltone,unlikethedistalconducting
system,whichdoesnot.Therefore,manoeuvresthatincreasevagaltoneworsenanAVnodalblockbutnotan
infranodalblock.Incontrast,atropineimprovesAVnodalblock(itwillspeedupheartrate),whereasitworsens
blockintheHisPurkinjesystem.
Inthiscase,theheartratewasunaffectedbythevagalmanoeuvrebutworsenedbyatropinethereforetheblockcan
belocatedtotheHisPurkinjesystem.
AVnode(OptionA)isincorrect.AstheblockcanbelocatedtotheHisPurkinjesystemthisisnotanappropriatechoice.
Leftbundlebranch(OptionC)isincorrect.AstheblockcanbelocatedtotheHisPurkinjesystemthisisnotan
appropriatechoice.
SAnode(OptionD)isincorrect.AstheblockcanbelocatedtotheHisPurkinjesystemthisisnotanappropriatechoice.
Unabletocommentfromthedatagiven(OptionE)isincorrect.AstheblockcanbelocatedtotheHisPurkinjesystem
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thisisnotanappropriatechoice.
41963
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Question49of295
A47yearoldmanpresentswithahistoryofnumerousmyocardialinfarctions(MIs)andisonaspirinafteranacuteMI.
Whichoneofthefollowingismostlikelytoprolonghissurvival?
A Carvedilol
B Isosorbidemononitrate
C Losartan
D Ramipril
E Statin
Explanation
TheanswerisRamipril
Inpractice,anumberoftheseinterventionswouldbecommencedtogether,butasthequestionasksspecificallyfor
oneintervention,thecorrectanswerisasstatedramipril.
Myocardialinfarction
Afterapatienthashadamyocardialinfarction(MI),itisimperativetoconsiderallmodifiableriskfactorsto
lowertheriskoffurthervascularevents.
Nonpharmacologicalinterventions
Themostimportantinterventionistostopsmokingafterjust1yearthereisasignificantdropintheriskof
MI.
Weightlossinanobeseindividualwillreducecomorbiditybuthasnotbeenshowntoprolongsurvival.
Itwouldbeethicallyimpossibletoarrangerandomisedtrialsofsmokingcessationorweightloss,sosuch
interventionshavetorelyonepidemiologicalevidencetojudgetheoutcome.
Pharmacologicalinterventions
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Intheotherinterventionstrialevidencehasgivenanumberofpatientsneededtotreatinordertopreventone
fatality(NNT),andthisisonewayofjudgingwhichinterventionhasthemostlikelihoodofprolonging
survival.
ForblockerstheNNTis143(ISIS1study).
ForaspirintheNNTis42(ISIS2study).
Forangiotensinconvertingenzyme(ACE)inhibitorstheNNTis22(SOLVD).
ForstatinstheNNTis33(CARE).
Carvedilol(OptionA)isincorrect.Carvedilolasdescribedwouldnotbetheoptionmostlikelytoprolongsurvivalof
thoseoffered.
Isosorbidemononitrate(OptionB)isincorrect.Isosorbidemononitrateisusedforthesymptomaticreliefofcongestive
heartfailureandasaprophylactictreatmentofangina.
Losartan(OptionC)isincorrect.LosartanisanangiotensinIIreceptorblockerusedinthetreatmentofhypertension.
Statin(OptionE)isincorrect.Thisasdescribedwouldnotbetheoptionmostlikelytoprolongsurvivalofthoseoffered.
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Question50of295
Whatistheconventionalcardiacmicroanatomicalstructuretargetedbycalciumchannelblockers?
A Ltypecalciumchannels
B CalciumchannelTtype
C Ttubules
D Titin
E Tropomyosin
Explanation
TheanswerisLtypecalciumchannels
Althoughthisquestionappearscomplex,itrequiresonlyabasicknowledgethatallconventionalcalciumchannel
blockersworkonLtypecalciumchannels.
Microanatomicalstructures
Ttubulesandcalciumchannels
TheTtubulesareatubularnetworkformedbytheinvaginationofthesarcolemmaofthemyocyte.
SarcolemmalcalciumchannelsarelocatedontheTtubules.
Therearetwomaintypesofchannels
T(transient)channelsdonotinteractwithconventionalcalciumchannelblockers.
Ltypecalciumchannelsdointeractwithcalciumchannelblockers
CalciumchannelTtype(OptionB)isincorrect.Tchannelsdonotinteractwithconventionalcalciumchannelblockers.
Ttubules(OptionC)isincorrectasdescribed.
Titin(OptionD)isincorrect.TitintethersthemyosinmoleculetotheZline,anditselasticityexplainsthestressstrain
elasticrelationofstriatedmuscle.Itisthelargestproteinmoleculeyetdescribed.
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Tropomyosin(OptionE)isincorrect.Thethinactinfilamentsintertwineandarecarriedonaheaviertropomyosin
moleculethatfunctionsasabackbone.Atregularintervalsalongthisstructureisagroupofthreeregulatoryproteins
calledthetroponincomplex,whichiscomposedoftroponinC,IandM.
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Question51of295
A62yearoldwomansuddenlydeteriorates2daysafterreceivingtPAforanacutemyocardialinfarction.Shecomplained
ofsevereshortnessofbreathduringthecourseoftheafternoonandwhenthenursesexaminedher,herO2saturationwas
only91%onoxygendeliveredviaanonrebreather.OnexaminationherBPis105/70mmHg,withapulseof105bpm
regular.Shehasanapicalsystolicmurmurandmarkedleftventricularfailure.Whichoneofthefollowingisthemost
likelycause?
A AcuteVSD
B AcuteASD
C Pericardialtamponade
D LVwallrupture
E Papillarymusclerupture
Explanation
Papillarymusclerupture
Thispatienthaspapillarymusclerupture
Outofthepossiblemuscleswhichmayrupture,theposteromedialpapillarymuscleistwiceaslikelytoruptureas
theanterolateralonebecausetheposteromedialpapillarymuscleissuppliedbytherightcoronaryarteryonly,
whereastheanterolateralpapillarymusclereceivessupplyfromboththeleftanteriordescendingandleft
circumflexarteries
Themurmurisconsistentwithmitralregurgitationwhichinturnleadstoacuteleftventricularfailure
Management
Managementcentresondecreasingafterloadinanattempttostabilisepatientsbeforeundergoingvalvularsurgery
Sodiumnitroprussideistheusualtherapyofchoicewherebloodpressureallows,asthiscanbecloselytitratedto
systolicBP
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Question52of295
A56yearoldmanhasknowntricuspidregurgitation.
Whichpartofthejugularvenouswaveformislikelytobemostprominent?
A awave
B cwave
C vwave
D xdescent
E ydescent
Explanation
Jugularvenouswaveformintricuspidregurgitation
Tricuspidregurgitationcharacteristicallycauseslossofthexdescentinthejugularvenouspressurecausingfusion
ofthecandvwavestoproducegiantvwaves,alsoknownascvwavesorswaves
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Question53of295
A72yearoldmanpresentswithanepisodeofcollapsewithlossofconsciousness.Hehadexperiencedtwosimilar
episodesrecently,eachlastingabout1min.Fouryearspreviouslyhesufferedananteriormyocardialinfarction.On
examinationhewasorientatedandsymptomfreewitharegularpulserateof80bpm,bloodpressure140/80mmHg,and
apexbeatdisplacedtotheleft.Therewasanapicalsystolicmurmur.Therewerenosignsoftrauma.The
electrocardiogram(ECG)showssinusrhythm,QwavesandSTsegmentelevationanteriorlywithoutreciprocal
depression.
Whatwasthecauseofthecollapse?
A Acuteanteriormyocardialinfarction
B Cerebrovascularaccident
C Epilepticseizure
D Pulmonaryembolism
E Ventriculartachycardia
Explanation
TheanswerisVentriculartachycardia
Ventriculartachycardia
Giventhehistoryofpreviousmyocardialinfarctionthathasleftfullthicknessscar(Qwaves),itismostlikelythat
thelossofconsciousnesswasduetoatransientepisodeofventriculartachycardia,whichresultsinaperiodof
circulatorycompromisethatleadstothecollapse.Inthesecases,VToccursduetoreentrantcircuitsaroundthe
myocardialscar.
InthiscasethediagnosiswouldbemadebyHoltermonitoringofhiselectrocardiogram(ECG)7daycardiac
monitorsprovidethemostdiagnosticinformation.Wheneventsaremoreintermittent,evenlongermonitorsare
availableandgivethebestchanceofcapturingaperiodofventriculartachycardia.
TheantiarrhythmicofchoicewouldbeamiodaronetosuppressreentrantVT.blockersshouldalsobegivento
suppressischaemiathatmaybetriggeringtransientVT.Anangiogramshouldbeperformedtoseekareversible
cause.VTstimulationstudiescanalsobeconsideredtoterminatecircuitsifitisarecurrentproblem.Patientsshould
alsobeconsideredforanimplantabledefibrillator.
Therearenoprodromaleventsreportedandthepatientisnotpostictalafterthecollapse.
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Acuteanteriormyocardialinfarction(OptionA)isincorrect.ThepersistentSTsegmentelevationinthiscasewouldnot
indicateacutemyocardialinfarction,butitislikelytorepresentleftventricularaneurysm,arecognisedcomplicationof
acuteanteriormyocardialinfarction.ThisissupportedbythepresenceofQwavesanteriorly.Myocardialinfarctionperse
doesnotdirectlycauselossofconsciousnessratheritisthearrhythmiasthatresultasaconsequence.
Cerebrovascularaccident(OptionB)isincorrect.Cerebrovascularaccidentsarerarelycausesoftruelossofconsciousness
inparticularshortlivedeventswherethepatientiswellbetweenepisodes.
Epilepticseizure(OptionC)isincorrect.Epilepticseizureisnotthemostlikelycauseforthisclinicalpresentation.
Pulmonaryembolism(OptionD)isincorrect.Pulmonaryembolismisnotthemostlikelycausefortheclinical
presentationdescribedhere.
41995
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Question54of295
A72yearoldmanpresentsforanextractionofthreeteethunderlocalanaesthesia.Hehasapasthistoryofrheumatic
heartdisease.Mitralstenosishasbeenidentified,buttherottenteetharebeingremovedbeforevalvereplacement.Heis
allergictopenicillin.
Whichoneofthefollowingwouldbethemostappropriateantibioticregimeforhim?
A Amoxicillin3gpo1hourbeforeprocedure
B Augmentin1gpobeforeprocedure
C Ciprofloxacin1gpo1hourbeforeprocedure
D Noprophylaxisnecessary
E Vancomycin1gpo1hourbeforeprocedure
Explanation
TheanswerisNoprophylaxisnecessary
Alternativestopenicillin
Atpresent,NICEguidelines(CG064)donotrecommendantibioticprophylaxisforanumberofroutine
procedures,includingdentalextraction.Theirconclusionisbasedonthefactthattheywereunableto
determineanyevidencewhichsuggestedthatantibioticprophylaxispreventedthedevelopmentof
endocarditis.Thisadviceincludespatientswithrheumaticheartdiseaseandthosewhohaveundergonevalve
replacement.
Somestudieshavesuggestedthattherehasbeenanincreaseintheincidenceofinfectiveendocarditissince
theseguidelineswerepublished.NICEispresentlyreviewingthedataandwillpublishnewguidelines.
Duetothiscontroversy,itispossiblequestionsonthismatterwillbeomittedbytheRCP.
Amoxicillin3gpo1hourbeforeprocedure(OptionA)isincorrect.Ifantibioticsweretobegiventhiswouldhavetobe
avoidedasheispenicillinallergic.
Augmentin1gpobeforeprocedure(OptionB)isincorrect.Ifantibioticsweretobegiventhiswouldhavetobeavoided
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asheispenicillinallergic.
Ciprofloxacin1gpo1hourbeforeprocedure(OptionC)isincorrect.Ciprofloxacinmaybegiveninpenicillinallergybut
antibiotictreatmentisnotrecommendedinthisinstance.
Vancomycin1gpo1hourbeforeprocedure(OptionE)isincorrect.Ifantibioticsweretobegivenvancomycincouldbe
usedhoweveroralvancomycinisonlyusedinC.difficileinfectionsduetolowabsorptionrates.
42023
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Question55of295
A54yearoldmanis48hpostmyocardialinfarction.Youareaskedtoreviewhimashehasnewpulmonaryoedemaand
fallingurineoutput.Onexaminationhehasapansystolicmurmur,loudestattheapex.
Whichoneofthefollowingcomplicationsofhismyocardialinfarctionismostlikelytohaveoccurred?
A Acutemitralregurgitation
B Acutepulmonaryregurgitation
C Atrialseptaldefect
D Ventricularrupture
E Ventricularseptaldefect
Explanation
TheanswerisAcutemitralregurgitation
Mechanicalcomplicationsoftreatedmyocardialinfarctionarenowthankfullyrare(acuteMR,VSDandventricular
rupture).Earlyreperfusionshouldpreventmost,butlatepresentinginfarctions,orthosethatcannotbeadequately
reperfused(eghighclotburdenwithchallengingcoronaryanatomy)willstillhavefullthicknessinfarctionwith
subsequentriskofcomplications.
Acutemitralregurgitationisthemostlikelyconditioninthispatient.Thereisaclear,loud,pansystolicmurmur
withpulmonaryoedema.Ascardiacoutputfallsfromtheacuteregurgitation(mostofthecardiacoutputisnow
returningtotheLA)therewouldbeafallinurineoutput.
Acutemitralregurgitation
Acutemitralregurgitationassociatedwithmyocardialinfarctionmayoccurduetorupturedchordaetendineae.This
ismorelikelyininfarctionsaffectingthelateralwall(egcircumflexvessel).
Othercausesofacutemitralregurgitationinclude:
papillarymuscledysfunctionfromacuteischaemia
infectiveendocarditis
rheumaticheartdisease
idiopathicmyxomatousvalvedegeneration
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leftatrialmyxoma
systemiclupuserythematosus(SLE)
drugs(fenfluramineanddexfenfluramine)
allofthesecanleadtoaruptureofachordae.
Theinvestigationofchoiceisechocardiography,whichmayidentifyleftatrialandleftventriculardilatationand
confirmthediagnosisofchordaetendineaerupture.
MitralregurgitationassociatedwithchordalruptureinMImaybecatastrophicandrequireemergencysurgeryfor
valvereplacement.
Acutemedicalmanagementinvolvestreatmentwithangiotensinconvertingenzyme(ACE)inhibition,diuretic
therapyandpossibleanticoagulation.
Theprognosisforpatientswithmitralregurgitationisgenerallygood,exceptinthepostmyocardialinfarction
situation.
Acutepulmonaryregurgitation(OptionB)isincorrect.Acutepulmonaryregurgitationisuncommonandwouldpresent
withadiastolicmurmurnotdissimilarfromAR.
Atrialseptaldefect(OptionC)isincorrect.Atrialseptaldefectisnotatypicalcomplicationofmyocardialinfarction.It
hasfixedsplittingofS2.
Ventricularrupture(OptionD)isincorrect.Ventricularruptureisarapidlyfatalconditionthepatienthassuddenchest
painfollowedbyhaemodynamiccollapse.Thereisunlikelytobeamurmurandtamponadefeaturesaremorelikelyas
bloodentersthepericardialspace.
Ventricularseptaldefect(OptionE)isincorrect.Ventricularseptaldefectsareidentifiedbyaloudpanorejectionsystolic
murmurthatisloudalloverthepraecordium,butoftenloudestatthelowersternaledge.Theremaybeathrill.
41991
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Question56of295
Youreviewa28yearoldwomanwithpalpitations.Onexaminationyoususpectthatthereissplittingofthefirstheart
sound.HerBPis123/80mmHg,pulse70bpmregular,andherchestisclear.Therearenoothercardiovascularfindings.
Youarrangea12leadECG.WhichoneofthefollowingpartsoftheECGismostcloselyassociatedwiththefirstheart
sound?
A Pwave
B Twave
C Swave
D Rwave
E Uwave
Explanation
Rwave
ThefirstheartsoundoccursmostcloselyinassociationwiththeRwave
Splittingofthefirstheartsoundmayoccurinatrioventricularseptaldefects(AVSDs)orinconditionssuchas
Ebsteinanomaly
InpatientswithAVSDthereisusuallyleftaxisdeviation,prominentPwavesandprolongationofthePRinterval
Echocardiographyandcardiaccatheterisationfollowtodeterminetheextentofthedefect
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Question57of295
A70yearoldwomanhadahistoryofdyspnoeaandpalpitationsfor6months.Anelectrocardiogram(ECG)atthattime
showedatrialfibrillation.Shewasgivendigoxin,diureticsandaspirin.Shenowpresentswithtwoshortlivedepisodesof
alteredsensationintheleftface,leftarmandleg.Thereispoorcoordinationofthelefthand,butshetellsyouthatthis
beganaround6monthsearlier.Theechocardiogram(ECHO)wasnormal,aswasacomputedtomography(CT)headscan.
Whichoneofthefollowingisthemostappropriatestepinlongtermmanagement?
A Anticoagulation
B Carotidendarterectomy
C Clopidogrel
D Corticosteroidtreatment
E Noaction
Explanation
TheanswerisAnticoagulation
Thispatienthashadastrokewithabackgroundofatrialfibrillation.Evenpriortothisstroke,herCHADS2VASc
scorewaselevatedandshouldhavebeenconsideredforlongtermanticoagulation.
Anticoagulation
Indications
Guidelinesstatethatanticoagulationisindicatedinpatientswithanyoneof:
prostheticheartvalve
priorhistoryofrheumaticheartvalvedisease
priorhistoryofstrokeortransientischaemicattack
ageolderthan75years
hypertensionorcoronaryarterydiseasewithpoorleftventricle(LV)function.
Otherriskfactorsthatoccurconcurrentlywithatrialfibrillationandsuggestaneedforpossibleanticoagulation
include(clinicianslookfortwoofthesemoderateriskfactors):
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diabetesmellitus
age6575years
coronaryarterydiseasewithnormalLVfunction.
ThesefeatureshavenowbeensummarisedintheCHA2DS2VAScscore,asdescribedbelow.
CHA2DS2VAScscore
Score1pointforcardiacfailure,hypertension,diabetes,vasculardisease,age6574,female.
Score2pointsforage75,previousstroke,TIAorthromboembolicevent.Maximumscoreis9becauseagecan
contribute0,1or2points.
0 0 Aspirinornil(preferred)
1 1.3 Aspirinorwarfarin
2 2.2 warfarin
3 3.2 warfarin
4 4.0 warfarin
5 6.7 warfarin
6 9.8 warfarin
7 9.6 warfarin
8 6.7 warfarin
9 15.2 warfarin
ACochraneanalysishassuggestedthatmostpatientswithatrialfibrillationshouldbeconsideredfor
anticoagulationunlesstherearespecificreasonsnotto.
Inthecaseofthiswomanshehassufferedatleasttwotransientischaemicattacks(TIAs),withsomeresidualpoor
damagetocoordinationintheleftarm,soshenowfitsthecriteriaforanticoagulation.
Carotidendarterectomy(OptionB)isincorrect.Cartoidendarterectomyshouldbeconsideredwhencarotidstenosesare
foundof>5099%accordingtoNorthAmericanGuidelines,or>70%accordingtotheEuropeanGuidelines.
Clopidogrel(OptionC)isincorrect.Clopidogrelmaybeusedinpatientswithsinusrhythmwhohaveastrokeaspartof
secondaryprevention.However,inthecontextofAF,anticoagulationshouldbeconsideredfirstline.
Corticosteroidtreatment(OptionD)isincorrect.Corticosteroidshavenoroleinthiscase.Inpatientswithintracranial
masseffect,steroidsmayhelptoreduceswellingbutarenotneededhere.
Noaction(OptionE)isincorrect.Forthereasonsdescribedthisisnotthebestcourseofactionforthiswoman.
41992
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Question58of295
A61yearoldmanisadmittedtotheEmergencyDepartmentbyambulance.Hereports3hoursofcentral,retrosternal,
pressingchestpain.Hesmokes10cigarettesperdayandhasahistoryofhypertensionforwhichhetakesAmlodipine
5mg.BythetimehearrivesinthehospitalhehasbeengivenAspirin300mgbytheparamedicstaff.Onexaminationhis
BPis142/92mmHgpulseis92/minandregular.Hiscentralchestpainisresolving.Auscultationrevealsaclearchest,
thereisnoankleswelling.
Investigations:
Hb 13.1g/dl
WCC 8.1x109/l
PLT 199x109/l
Na+ 138mmol/l
K+ 4.7mmol/l
Creatinine 110micromol/l
Glucose 8.1mmol/l
ECG AnteriorTwaveinversion
hsTroponin 2.1(elevated)
CXR unremarkable
Whichofthefollowingisthemostappropriatenextstep?
A Bivalirudin
B Clopidogrel
C Enoxaparin
D Fondaparinux
E Ticagrelor
Explanation
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Explanation
TheanswerisFondaparinux
Onceaspirinisgiven,thenextstepaccordingtoNICEclinicalpathwaysistogiveFondaparinux2.5mgonlyif
angiographyislikelywithin24hrsshouldunfractionatedheparinbegiven.FollowingFondaparinux,atthisstage,withan
elevatedtroponinandECGchanges,furtherantiplatelettherapyisneeded.OptionsincludeClopidogrel300mgor
Ticagrelor(whichcanbeusedinthe>60yearspopulation),accordingtolocalguidelines.Bivalirudinisanalternative
therapyforpatientswithanacuteinfarctundergoingPCI.
http://pathways.nice.org.uk/pathways/acutecoronarysyndromes#path=view%3A/pathways/acutecoronary
syndromes/earlymanagementofunstableanginaandnstemi.xml&content=viewnode%3Anodesinitialtreatment
(http://pathways.nice.org.uk/pathways/acutecoronarysyndromes#path=view%3A/pathways/acutecoronary
syndromes/earlymanagementofunstableanginaandnstemi.xml&content=viewnode%3Anodesinitialtreatment)
40183
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Question59of295
A50yearoldmanunderwentcoronaryarterybypassgrafting2daysago.Aroutineliverfunctiontestresultnowshows
thatboththedirectandindirectbilirubinareelevated.Alltheotherliverfunctiontestsarenormal.
Whichoneofthefollowingisthemostlikelycause?
A Shockliversyndrome
B Anaestheticinduced
C Haemolysisonbypass
D Narcoticinduced
E Rightheartfailure
Explanation
Haemolysisoncardiopulmonarybypass
Isolatedelevationofdirectandindirectbilirubin,indicateshaemolysisonthecardiopulmonarybypassandcanbe
confirmedbyincreasedplasmafreehaemoglobinlevels
Thereisnospecifictreatment
Othernotes
Markedlyraisedenzymelevelsareseeninpatientswiththeshockliversyndrome,andthetreatmentisaimedat
maximisingcardiacoutputandoxygenation
Rightheartfailureisanothercauseofhyperbilirubinaemiaintheimmediatepostbypassperiod,and,inthiscase,
thedirectbilirubinandalkalinephosphataseareincreasedwithoutenzymeelevation
Treatmentisasforrightheartfailure
904
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Question60of295
A30yearoldwomanpresentswitha3monthhistoryofchestpain.Onauscultation,thereisamidsystolicclickanda
latesystolicmurmur.HerECGshowsTwaveinversionsinleadsIIandIII,andaVF.
Whichoneofthefollowingstatementsconcerningherconditionistrue?
A Coronaryarterydiseaseishighlylikelyinthiscase
B Theclickandmurmurislikelytooccurearlierinsystolewhenthepatientstands
C AnexercisestresstestwouldlikelyshowsevereSTdepression
D Asymmetricalhypertrophyoftheinterventricularseptumisrevealedonechocardiography
E PrimaryprophylacticICDinsertionshouldbeconsidered
Explanation
TheanswerisTheclickandmurmurislikelytooccurearlierinsystolewhenthepatientstands
Systolicclickmurmursyndrome
Thispatienthasfeaturesofthesystolicclickmurmursyndromewhichfeaturesmitralvalveprolapseandrecurrent
noncoronarychestpains.
Itoccursinapproximately4%ofthenormalpopulation.
Itcanplaceexcessivestressonthepapillarymusclesandleadtoischaemiaandchestpain,butwithoutthepresence
ofsignificantcoronarydisease.
OnstandingorduringtheValsalvamanoeuvre,asventricularvolumegetssmaller,theclickandmurmurmove
earlierinsystolethisisaclassicalfindingofmitralvalveprolapse.ThereforeanswerBiscorrect.
Echocardiogramrevealsmidsystolicprolapseoftheposteriormitralleafletor,onoccasion,bothmitralleaflets
intotheleftatrium
Coronaryarterydiseaseishighlylikelyinthiscase(OptionA)isincorrect.Asdescribeditcanplaceexcessivestresson
thepapillarymusclesandleadtoischaemiaandchestpain,butwithoutthepresenceofsignificantcoronarydisease.
AnexercisestresstestwouldlikelyshowsevereSTdepression(OptionC)isincorrect.Thisisunlikelywithoutsignificant
coronarydisease,despitetheabnormalityonrestingECG.
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Asymmetricalhypertrophyoftheinterventricularseptumisrevealedonechocardiography(OptionD)isincorrect.
Asymmetricalhypertrophyoftheinterventricularseptumisafeatureofhypertrophicobstructivecardiomyopathy
(HOCM)thereforeanswerDisincorrect.
PrimaryprophylacticICDinsertionshouldbeconsidered(OptionE)isincorrect.ThereisnoneedtoconsideranICDin
thispatientthisconditionisassociatedwithagoodprognosisandthereisnoincreaseinthelikelihoodofsuddencardiac
death.
41948
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Question61of295
A45yearoldmanwasdiagnosedwithnewonsetatrialfibrillationaftervisitinghisGPcomplainingofpalpitations.An
ECGconfirmedatrialfibrillationwithaventricularrateof85bpm,andanECHOdidnotrevealanysignificantstructural
heartdisease.Onadviceofthehospitalhewasgivenlowmolecularweightheparinandstabilisedonwarfarin,withan
INRof2.5.Youarrangeforhimtobecardiovertedafewweekslater,andtheprocedureissuccessful.Accordingto
currentguidelines,howlongisitrecommendedtocontinuehiswarfarintherapy?
A Forlife
B For1week
C For72h
D For4weeks
E For6months
Explanation
Warfarinisation
Guidelinespublishedin2006recommendwarfarinisationforatleast3weeksprecardioversionandfor4weeks
postcardioversion
Theaimisforatargetinternationalnormalisedratio(INR)of2.5,althoughthiscanbeallowedtodriftupto3a
fewdaysbeforetheproceduretominimiseanyrisksofcancellationduetoinadequateanticoagulation
Theperiodof4weekspostprocedureisrecommendedbecausethereisahighrelapserateinthefirstfewweeks
18565
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Question62of295
A62yearoldpatientwithunderlyingischaemicheartdiseasehadtwotransientepisodesoflossofconsciousnessbut
feelsfineatpresent.Bothepisodeswereprecededbyafeelingofdizzinessandvisiongoingblack,andwitnessesreport
thatthesubjectwentverypaleandthencollapsed,lyingmotionlessforafewsecondsbeforemakingarapidrecovery.No
abnormalmovementswereseenduringtheperiodofunconsciousnessandtherewerenoexternalsignsofaheadinjury.
ExaminationrevealsaBPof135/75mmHg,pulseis70/minandregular.Therearebibasalcracklesonauscultationofthe
chest.Routinebloodsareunremarkable,andaCXRrevealscardiomegaly.
Whichoneofthefollowinginvestigationsshouldyouordernext?
A Echocardiography
B Computedtomography(CT)ofthehead
C 24helectrocardiogram(ECG)
D Cardiaccatheterisation
E Treadmilltest
Explanation
Thepatientpresentingwithtransientepisodesoflossofconsciousness
Thekeyinassessinganyepisodeoflossofconsciousnessisadetailedhistoryincludingeyewitnessdescriptions
Thisisnecessarytotrytoclinicallydistinguishbetweenthemanydifferentpossibleaetiologiesofsuchan
occurrence
Inthiscasethepresyncopalsymptoms,aswellasthebriefnatureoftheattack,pallor,lackofconvulsionsand
priorcardiachistoryareinfavourofeitherneurogenicsyncopeoranarrhythmia
Cardiacsyncope
Lossofconsciousnessofcardiacoriginmayresultfromabnormalitiesofheartrhythm,duetoextremesofrate,
eitherfastorslow,orfromsomemajordisturbanceofcardiovascularfunction,withresultantreducedcerebral
perfusion
Theimportanceinestablishingthediagnosisofcardiacsyncopeistheassociatedadverseprognosis,whichmaybe
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improvedwithappropriatetreatment
Theprobabilityofcardiacsyncopeisincreasedinthepresenceofstructuralcardiovasculardiseaseidentifiedfrom
thehistory,clinicalexaminationorinvestigation
Syncopeisdefinedasatransientlossofconsciousnesswiththelossofposturaltone,andismostcommonlydue
tocardiovascularmechanismsresultinginreducedcerebralperfusion
Itisacommonpresentation,resultingin12%ofEmergencyDepartmentvisitsandupto6%ofhospital
admissions
Thecauseisofteninitiallyuncertain,andassessmentmustfirstdifferentiatesyncopefromothercausesoflossof
consciousness,inparticularepilepticseizures
Thenextpriorityistoidentifyhighriskpatients
Documentationofcardiacrhythmduringsyncopeisdesirable,butisdifficulttoobtainbecauseoftheintermittent
andusuallyinfrequentnatureofthesymptom
Holtermonitoringisunlikelytorecordtherhythmduringanepisode,butmayprovideevidenceoflesserdegrees
ofabnormality,whichmaysupportadiagnosissuchassinoatrialdysfunction
5590
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Question63of295
A30yearoldpostmanwithhypertensionbutnormallyingoodhealthpresentstotheEmergencyDepartmentwithsudden
severebreathlessnessandsweating.Chestexaminationrevealsbilateralbasalcrackles.Heimproveswithdiamorphineand
frusemide(furosemide).ECGandcardiacenzymesarenormal.Hedevelopstwofurtherepisodesofpulmonaryoedema
whichrespondwelltodiuretics.Investigationsinthefollowupclinicrevealevidenceofleftventricularhypertrophyon
chestxraybutwithapreservedejectionfractiononechocardiogram,andanelevatedcreatinineof145mol/l.
Whatisthemostlikelycauseofpulmonaryoedema?
A Dilatedcardiomyopathy
B Myocarditis
C Ischaemicheartdisease
D Phaeochromocytoma
E Renalarterystenosis
Explanation
Renalarterystenosis
Thedifferentialdiagnosisofacutepulmonaryoedemaincludes
severeleftventriculardysfunction
paroxysmalarrhythmias
threevesselorleftmainstemcoronarydisease
Inthecontextofhypertensionitalsoincludes
renalarterystenosis
phaeochromocytoma
Renalarterystenosisismorecommon
Thismanisapostmanandtherforewouldbeexpectedtohavereasonableexercisetolerance,givenhisagethis
makescardiomyopathy,myocarditisandischaemicheartdiseaseextremelyunlikely
Renalarterystenosisina30yearoldismuchmorecommonthanphaeochromocytoma
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Question64of295
AnAsianboywithaknownhistoryofrheumaticheartdiseasepresentswithlowgradefeverforthepastmonth.He
receivedacourseofantibioticsfromhisGPaweekago.Whichoneofthefollowinginvestigationswouldbemostuseful
inthediagnosis?
A Bloodculture
B Serologicaltesting
C Echocardiogram
D Creactiveprotein
E Fullbloodcount
Explanation
Useofechocardiographyforvisualisingvegetationsininfectiveendocarditis
Echocardiographyisextremelyusefulinallowingvegetationsininfectiveendocarditistobeseen
Althoughbloodculturesareakeydiagnostictestinthiscondition,theymaybenegativeifpatientshaverecently
receivedantibiotictherapy
ThesamereasoningappliestoserologicaltestsforCoxiella,Bartonella,Legionella,ChlamydiaandBrucellaspp
thatmayalsocauseinfectiveendocarditis
BothCreactiveproteinandpolymorphonuclearleucocytosisarenonspecifictests
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Question65of295
A63yearoldsmokerisadmittedwithnausea,sweatingandcentralcrushingchestpain.A12leadECGrevealsST
elevationinleadsII,IIIandaVF.Whichcoronaryarteryismostlikelytohavebeenaffectedinthiscase?
A Circumflexartery
B Leftanteriordescendingartery
C Rightcoronaryartery
D Obtusemarginalartery
E Posterolateralartery
Explanation
Bloodsupplytotheheart
Therightcoronaryarterygenerallysupplies:
therightventricle
theposteriorthirdoftheinterventricularseptum
theinferiorwalloftheleftventricle
aportionoftheposteriorwalloftheleftventricle
Occasionallytheposteriorinterventricularseptummaybesuppliedbyabranchoftheleftcircumflexartery:aso
calledleftdominantcirculation
Theleftanteriordescendingandleftcircumflexcoronaryarteriesariseattheleftmaincoronaryarterybifurcation
andsupply:
theanteriorleftventricle
thebulkoftheinterventricularseptum(anteriortwothirds)
theapex
thelateralandposteriorleftventricularwalls
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Question66of295
Anelderly,normotensivemanwithknownsevereleftventriculardysfunctionpresentswitharegularbroadcomplex
tachycardia.Hisbloodpressureisstableat125/70mmHghispulseis145bpm.ApreviousECGinhisrecordsshows
thathewasinleftbundlebranchblock2yearsearlier.Heisalertandabletorespondtoquestions.
Whichoneofthefollowingdrugswouldbethefirstchoiceintreatmentofhisunderlyingrhythm?
A Sotalol
B Amiodarone
C Verapamil
D Lidocaine
E Flecainide
Explanation
TheanswerisAmiodarone
Aregular,broadcomplextachycardiainapatientwithstructuralheartdiseaseislikelytobeventriculartachycardia
andshouldbetreatedassuchuntilprovenotherwise.Inthisspecificcase,asinusECGwithLBBBandarateof
~150bpmmaypointtoanSVTwithaberrantconductionhowever,furtherinformationwouldbeneededtosafely
diagnosethisandmanagethecasedifferently.Therefore,thecorrectanswerwillalwaysrequirethepatienttobe
managedasVT.
Asthepatientdoesnothaveanyadversefeatures,thefirstlinetherapyisIVamiodarone(asrecommendedbythe
ResuscitationCouncil(UK)AdultTachycardiac(withpulse)algorithm).Amiodaroneshouldbeadministeredviaa
centralvenouscatheter.Avoidusingperipheralcannulaeastheriskoftissuedamageifthereisextravasationishigh.
IftherhythmwasanSVTwithaberrantconduction,thisisalsoanappropriatetreatment.
Sotalol(OptionA)isincorrect.Inthecontextofpoorleftventricularfunctionsotalolmayprovokecirculatorycollapse.
Verapamil(OptionC)isincorrect.Inthecontextofpoorleftventricularfunctionverapamilinparticularmayprovoke
circulatorycollapse.
Lidocaine(OptionD)isincorrect.Inthecontextofpoorleftventricularfunctionlidocainemayprovokecirculatory
collapse.
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Flecainide(OptionE)isincorrect.Flecainide,aswithallantiarrhythmics,canhaveaproarrhythmiceffectinthis
circumstanceitmayprecipitateventricularfibrillation.Theuseofflecainideinpatientswithpriormyocardialinfarction
wasshowntosignificantlyincreasemortalityintheCASTrandomisedcontrolledtrial.Assuch,flecainideshouldbe
avoidedinthosepatientswithknownischaemicheartdisease.
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Question67of295
A62yearoldmanwithabloodpressureof160/98mmHg,totalserumcholesterolof6.5mmol/landHDLof1.3mmol/l
isseenbyhisGP.Onreviewinghisrecordsitappearsthenursehasalsodocumentedhypertensivebloodpressurereadings
athislasttwowellmanchecks.Heisnotdiabeticandhasneversmoked.Hisfamilyhistoryisunknownashewas
adopted.Thereisahistoryofexertionalangina,whichisworseonhillclimbingandwhenwalkinghisdogincold
weather.
Apartfromadviceonlifestylemodification,whichoneofthefollowingcombinationofdrugsshouldhereceiveunder
currentguidelines?
A Aspirin,antihypertensivetreatment
B Statin,aspirin
C Clopidogrel,aspirin,statin
D Antihypertensivetreatment,aspirin,statin
E Antihypertensivetreatment,clopidogrel,statin
Explanation
TheanswerisAntihypertensivetreatment,aspirin,andastatin
Basedonaclassicalhistoryofanginainamanaged>55withatotalcholesterol>6.47mMyoucanmakeaclinical
diagnosisofcoronaryarterydiseasewithaprobability>90%(NICEguidance95).Therefore,aspirinshouldbe
recommendedasthefirstlineantiplateletagent.Astatinshouldalsoberecommended.
Theselectionofantihypertensiveagentsshouldbetailoredtothosethatprovidesymptomaticbenefitsuchas
blockersorcalciumchannelinhibitors,andprognosticbenefitsuchasACEinhibitors(NICEguidance126).
Aspirin,antihypertensivetreatment(OptionA)isincorrect.Thiscombinationlacksthestatin.
Statin,aspirin(OptionB)isincorrect.CurrentNICEguidanceencouragestheuseofambulatorybloodpressure
monitoring(NICEguidance127)beforetreatmenthowever,withtwopreviousreadingsandevidenceofendorgan
diseaseantihypertensivetherapyshouldbeinitiatedatthisappointment.
Clopidogrel,aspirin,statin(OptionC)isincorrect.Accordingtoguidanceaspirinshouldberecommendedasthefirstline
antiplateletagent.
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Antihypertensivetreatment,clopidogrel,statin(OptionE)isincorrect.Accordingtoguidanceaspirinshouldbe
recommendedasthefirstlineantiplateletagent.
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Question68of295
An18yearoldstudentisadmittedfromanightclubinastateofcollapse.OnadmissiontotheEmergencyDepartment
hisbloodpressureis90/45mmHg,andhehasapulseof190bpm.ECGrevealsanarrowcomplextachycardia,whichis
terminatedwithadenosine.ECGafterterminationofthetachycardiarevealsaPRintervalofapproximately100ms,anda
slurredQRScomplexwithdeltawave.
Whatdiagnosisfitsbestwiththisclinicalpicture?
A Amphetamineoverdose
B Cocaineoverdose
C Hypokalaemiainducedarrhythmia
D LownGanongLevinesyndrome
E WolffParkinsonWhitesyndrome
Explanation
TheanswerisWolffParkinsonWhitesyndrome
TheECGdescriptionisclassicalforWolffParkinsonWhitesyndrome.Featuresoftheotherconditionsarenot
presentandthereforetheseconditionsarenottherightanswer.
WolffParkinsonWhitesyndrome
WolffParkinsonWhite(WPW)syndromeisduetoacongenitalaccessorycardiacconductionpathway,
calledthebundleofKent,thatconnectstheatriatotheventricles,enablingelectricalactivitytobypassthe
atrioventricularnode.Therecanbemorethanonepathwayandthesemayconductantegrade(towardsthe
ventricle),retrograde(towardstheatria),orinbothdirections.
ECGabnormalitiesarecharacterisedbythepresenceofaPRinterval<120msandaQRScomplex>120
mswithslurred,slowlyrisingonset(deltawave).
Theypresentwithparoxysmaltachycardiasin10%ofpatientsaged2040years,and35%ofsufferersaged
over60years.
Commontypesofarrhythmiaatpresentationincludereciprocatingtachycardiaat150250bpm(80%),atrial
fibrillation(15%)andatrialflutter(5%).
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Thankfully,presentationwithventriculartachycardiaisrare.
PrevalenceintheUKpopulationisaround0.15%,beingmorefrequentinmales.
MostWPWpatientshaveanormalheartstructure,buttheremaybeassociatedmitralvalveprolapse,
cardiomyopathyorEbsteinsanomalyincertainpatients.
Treatment
Electricalcardioversionistheinterventionofchoicefornarrowcomplextachycardiasinthissituationin
whichpatientsarehaemodynamicallycompromised.
Inthenonacutestage,radiofrequencyablationoftheaccessorypathwaymaybeattempted.
Amphetamineoverdose(OptionA)isincorrect.Patientswithamphetamineoverdosepresentwithdisorientation,
agitation,asensationofinsectscrawlingovertheskin,frequentlywithchestpainandpalpitations.Theirmouthmaybe
dryandtheymaybeverysweaty.Somecanhavestrokelikeevents.
Cocaineoverdose(OptionB)isincorrect.Patientswithcocaineoverdosefrequentlyhaveseverechestpainfromcoronary
vasospasmandmaygoontohaveatruemyocardialinfarctionwithtroponinrise(prolongedvasospasmwillreduceflow
and/orallowinsituthrombosis).Bloodpressureistypicallyveryhighwithatachycardiaandectopy.Patientsmayalso
havesevereheadachefromintracranialvasospasm.Bodytemperatureisfrequentlyraisedandtheyareexcitedand
agitatedwithrestlessness.
Hypokalaemiainducedarrhythmia(OptionC)isincorrect.Potassiumisessentialfornormalcardiacelectricalactivity.
HypokalaemiacausesprolongationofthePRintervalwithSTdepressionandUwaves.Inthiscase,thereisshorteningof
thePRintervalandthereforethisisnotthecorrectanswer.
LownGanongLevinesyndrome(OptionD)isincorrect.LownGanongLevinesyndromeisaconditioninwhichthere
isanaccessorypathwaythatisclosetotheAVnodeitconnectstheleftatriumtotheHisbundle.Sinceitbypassesthe
AVnodeitshortensthePRinterval.However,sinceitconnectsdirectlytotheHisbundle,thereisnoabnormal
conductionacrosstheventricleandthereforethereisnodeltawave.AshortPRintervalwithoutdeltawaveandrecurrent
palpitations/collapsewouldfitwithLownGanongLevine,butinthiscasethereisadeltawave,pointingtoWolff
ParkinsonWhite.
42011
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Question69of295
A16yearoldyoungmanhadacardiacarrestwhileplayingfootballandwasresuscitated.Herecoveredfullyandwas
laterfoundtohaveHOCM(hypertrophicobstructivecardiomyopathy).Whichoneofthefollowingisthebesttreatment
option?
A Implantablecardioverterdefibrillator
B Amiodarone
C Blockers
D Verapamil
E Rateresponsive,dualchamberpacemaker
Explanation
Hypertrophicobstructivecardiomyopathy
Forthesecondarypreventionofsuddencardiacdeath(SCD)inpatientswithHOCM,thereisevidenceand
generalagreementthatimplantablecardioverterdefibrillatoristhemostusefuloption
EvenfortheprimarypreventionofSCDinHOCM,theweightofevidenceiscurrentlyinfavourofitsefficacy,
althoughinselectedpatientsamiodaronehasarole
OptionsC,DandEarenotconsideredeffectiveinpreventingSCDinHOCM
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Question70of295
A39yearoldwomancomestotheEmergencydepartmentwithaseverecrushingfrontalheadache,whichshe
describesastheworstshehaseverhad.Shehassufferedincreasingheadachesinthemorningoverthepast3months,but
putsthisdowntostressassheisundergoinginvestigationsforhypercalcaemia.Youunderstandhermotherdiedfroma
strokeatayoungage.OnexaminationherBPis190/100mmHg,pulseis95/minandregular.Shelooksanxious.Thereis
evidenceofhypertensiveretinopathyonfundoscopy.
Investigations
Hb 12.9g/dl
WCC 9.1x109/l
PLT 203x109/l
Na+ 138mmol/l
K+ 3.9mmol/l
Creatinine 110micromol/l
Calcium 3.05mmol/l
Whichofthefollowingislikelytobethemostappropriatestepinmanagingherbloodpressure?
A Labetolol
B Hydralazine
C Phenoxybenzamine
D Ramipril
E Sodiumnitroprusside
Explanation
TheanswerisPhenoxybenzamine
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Whilstsodiumnitroprussideandlabetololarebothusedinthemanagementofacceleratedhypertension,thecluesinthis
patientarethefamilyhistoryofdeathfromastrokeandthehypercalcaemia,whichmightbepointerstomultiple
endocrineneoplasiaType2(MEN2).Phenoxybenzaminetoachievealphablockadeisthereforethetreatmentofchoice.
Agentswhichachieveanelementofbetablockade,suchaslabetolol,arenotrecommendeduntilcompletealphablockade
hasbeenachieved.
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Question71of295
An80yearoldmanwithahistoryofintermittentatrialfibrillationpresentswithsyncope.ECGdocumentsatypeII,
seconddegreeAVblock.
Whichoneofthefollowingtypesofpacemakerisbestindicatedforhim?
A DDD
B DDDR
C VOO
D VVI
E VVIR
Explanation
Typesofpacemaker
Thereisasuspicionherethatthispatientprobablyhassinusnodediseasewithintermittentatrialfibrillation(AF)
andperiodsofheartblock
InapatientwithlongperiodsofAF,asinglechamberdevice(VVI)isindicated
Theadditionofratemodulation(VVIR)makesitevenbetter
ADDD(atrialsensing)deviceisnotindicatedinthiscase,sinceitwillinappropriatelysenseallthefibrillatingP
wavesandcandefeattheobjective
AVOO(ventricularpacingonly)devicewillsimplypacetheventricle,andthereisariskthatifthepacingfallsin
therelativerefractoryperiodoftheventricle,itcaninducetheRonTphenomenon,whichcanleadonto
ventriculartachyarrhythmia(VT)andventricularfibrillation(VF)
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Question72of295
A67yearoldmanisadmittedwithchroniccongestiveheartfailure.
Basedonthishistory,whatisthemostimportantfactortobekeptinmindwhenprescribingdrugsforthispatient?
A Administrationofablockerreducesthetimespentinhospital
B Administrationofspironolactonehasnoeffectontheincidenceofsuddencardiacdeath
C AngiotensinIIreceptorantagonistshaveabetterresponseratethanACEinhibitors
D DigoxinismoreeffectivethanACEinhibitorsinreducingcardiovascularevents
E Loopdiureticadministrationwouldresultinadecreaseinmortality
Explanation
TheanswerisAdministrationofablockerreducesthetimespentinhospital
Prescribingdrugsforheartfailure:Betablockers
Betaadrenoceptorblockingagents(metoprolol,bisoprololandcarvedilol)havebeenfoundtobeusefulinpatients
withchronicstableheartfailure.
ThestudiesMERITandCIBIS2,usingtheblockersmetoprololandbisoprolol,respectively,haveshown
improvedsymptomaticclass,exercisetolerance,leftventricularfunctionandreducedmortalityinheartfailureof
anycause.
Therapiddecreaseinsymptomsreducesthetimespentinhospitalandthishasbeenborneoutintrials.
Otherdrugs
Angiotensinconvertingenzyme(ACE)inhibitorsarerecommendedinallpatientswithclinicalheartfailure,as
ACEinhibitorsreducemortalityratesbyatleast20%.
Administrationofspironolactonehasnoeffectontheincidenceofsuddencardiacdeath(OptionB)isincorrect.
Spironolactonesignificantlyreducesthemortalityandsuddencardiacdeathratesandshouldbeaddedtothetreatmentin
allpatientswithNYHAIIIorIV.
AngiotensinIIreceptorantagonistshaveabetterresponseratethanACEinhibitors(OptionC)isincorrect.Angiotensin
IIreceptorantagonistshavenotbeenshowntobebetterthanACEinhibitors,andthereforeareprincipallyusedwhen
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thereisachroniccoughwithanACEinhibitor(in10%ofpatients).
DigoxinismoreeffectivethanACEinhibitorsinreducingcardiovascularevents(OptionD)isincorrect.Digoxinis
increasinglyrelegatedtothosewithadvancedheartfailure(classIV)anddoesnothavestrongdatatodemonstratea
mortalitybenefit.
Loopdiureticadministrationwouldresultinadecreaseinmortality(OptionE)isincorrect.Diureticadministrationis
associatedwitharapiddecreaseinsymptoms,butmortalityratesareunchangedtherearesomedatatosuggestloop
diureticuseisassociatedwithincreasedmortality,buttheremaybeconfoundingbyindication.Itisappropriatetostopthe
loopdiureticsonceexcessivefluidhasbeenremoved.
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Question73of295
A26yearoldwomanattendsherGPforaninsurancemedical.Herpreviousmedicalhistoryisunremarkable.On
examination,herBMIis21,bloodpressureis105/62mmHg,andauscultationoftheheartrevealsamidsystolicclickand
alatesystolicmurmurattheapex,whichisaccentuatedinthestandingposition.
Whatdiagnosisfitsbestwiththisclinicalpicture?
A Atrialseptaldefect
B Constrictivepericarditis
C Mitralregurgitation
D Mitralstenosis
E Mitralvalveprolapse
Explanation
TheanswerisMitralvalveprolapse
Thepicturebestfitswithmitralvalveprolapse.Theotherconditionshaveotherfeaturesnotpresenthere.
Mitralvalveprolapse
Mitralvalveprolapseistheposteriorbulgingofleafletsofthemitralvalveinsystole.
Mitralvalveprolapseisthoughttobepresentinaround4%ofthepopulation.
Clinically,patientswithmitralvalveprolapseareoftenyoungfemaleswithanarrowanteroposterior(AP)chest
diameter,lowbodyweightandlow/normalbloodpressure(allofwhicharepresentinthiscase).
Epidemiology
Increasedincidenceisassociatedwith:
autoimmunethyroiddisease
EhlersDanlossyndrome
Marfansyndrome
pseudoxanthomaelasticum
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pectusexcavatum.
Investigations
Cardiacauscultationrevealsamidtolatesystolicclick,bestheardattheapex,andamidtolatesystolicmurmur.
Echocardiographyrevealsbulgingoftheanteriorandposteriormitralvalveleafletsinsystole.
Associatedembolicphenomena(strokeortransientischaemicattack(TIA))arerare.
Complications
Theincidenceofcomplicationsofmitralvalveprolapseisthoughttobelessthan1%peryear,andtreatmentis
oftennotrequired.
Atrialseptaldefect(OptionA)isincorrect.Atrialseptaldefect(ASD)isassociatedwithfixedsplittingofS2andwould
notchangewithpositionchange.
Constrictivepericarditis(OptionB)isincorrect.ConstrictivepericarditiswouldhavearaisedJVP,withKussmaulssign.
ThereisahighpitchedsnapthatrepresentsS3rapidventricularfillingintoastiffpericardialsac.Thisissometimes
referredtoasapericardialknock.
Mitralregurgitation(OptionC)isincorrect.Mitralregurgitationisaloudpansystolicmurmurthatradiatesintotheaxilla.
Mitralstenosis(OptionD)isincorrect.Mitralstenosisisaquietdiastolicmurmur,oftenwithconcomitantatrial
fibrillation.
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Question74of295
A70yearoldwomanwithlongstandinghypertensionisreferredtooutpatientswithadiagnosisofasymptomaticatrial
fibrillation.Echocardiographydemonstratesnormalleftventricularfunction,mildleftventricularhypertrophy(LVH)and
normalmitralvalvestructure.Theleftatriumisslightlyenlarged(4.2cm).Sheisnotkeenoncardioversionandherrateis
wellcontrolledat70bpm.
Whatwouldbetheoptimalstrategyforlongtermanticoagulation?
A Aspirin
B Clopidogrel
C Dipyridamole
D Lowmolecularweightheparin
E Warfarin
Explanation
TheanswerisWarfarin
Atrialfibrillation
Atrialfibrillation(AF)iscommonandaffectsaround25%ofthepopulationwhoareover60yearsold.
Riskfactors
Itconfersanapproximatefivefoldincreasedriskofstroke.
Theabsoluteriskofstrokeisrelatedtothecoexistenceofothercardiovasculardisease.
ThiscanbeestimatedfromtheCHA2DS2VAScscore(shownintheaccompanyingtable).Althoughnotallthe
featuresaregiveninthequestion,wecanestimatetheriskeasily.
Heragescores1,femalegenderscoresanother,withanotherpointforhypertension:thereforewithoutanyother
information,shescores3,whichisaclearindicationforformalanticoagulation.
CHA2DS2VAScscore
Score1pointforcardiacfailure,hypertension,diabetes,vasculardisease,age6574,female
Score2pointsforage75,previousstroke,TIAorthromboembolicevent
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Maximumscoreis9becauseagecancontribute0,1or2points
0 0 Aspirinornil(preferred)
1 1.3 Aspirinorwarfarin
2 2.2 warfarin
3 3.2 warfarin
4 4.0 warfarin
5 6.7 warfarin
6 9.8 warfarin
7 9.6 warfarin
8 6.7 warfarin
9 15.2 warfarin
Treatment
InpatientswithAFandadditionalriskfactorsforstroke,suchashypertension,warfarinhasbeenshowntobe
superiortoantiplatelettherapy(primarilyaspirin)(ieaCHADSVAScscore1)
ACochranesystemicreviewhasconcludedclearsuperiorityofwarfarinoverantiplateletagentsinnonvalvular
AF
warfarincouldbeexpectedtoprevent30strokesattheexpenseofsixmajorbleedingevents
theuseoflowdosewarfarinorlowdosewarfarincombinedwithaspirinwasfoundtobeoflittlebenefitfor
strokeprevention.
Ifthereiscontraindicationtowarfarin,thepatientcannottolerateitortheyexpressastrongpreference,thena
NOAC(nonvitaminKantagonistoralanticoagulants)suchasapixaban,rivaroxabanordabigatrancanbe
considered.Theseneweragentsdonotrequireregularmonitoring,whichmakesadministrationeasier.Inthestudies
theyappeartobeasefficaciousaswarfarinwithbeneficialbleedingprofilesthedifficultyisthatthereisnowayof
monitoringcompliance,asthereisnoreadilyavailablebloodtest.
Othernotes
Thispatienthasevidenceofstructuralcardiacdiseasewithleftventricularhypertrophyandanenlargedleftatrium,
therebyreflectingahigherriskofdevelopingathromboemboliccomplication.
Aspirin(OptionA)isincorrect.Aspirinhasbeenshowntobeinferiortowarfarininthissituation.
Clopidogrel(OptionB)isincorrect.Thereisnoroleforclopidogrelinthiscohort.
Dipyridamole(OptionC)isincorrect.Thereisnorolefordypridamoleinthiscohort
LMWH(OptionD)isincorrect.LongtermLMWHischallengingandcantriggerosteoporosisandheparininduced
thrombocytopenia.
41937
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Question75of295
A32yearoldwomanisadmittedinanunconsciousstateafteranoverdoseofalargenumberofamitriptylinetablets.Itis
thoughtthatshetookthembetween7and8pmandwasnotfoundbyherpartneruntilhereturnedfromabarsome3
hourslater.WhenyouseehershehasalreadybeenintubatedbytheEmergencyDepartmentconsultant.HerBPis100/70
mmHgandshehasasinustachycardiaof100bpm.Whileyouarewatchingthemonitoryoucanseesheissufferingfrom
shortunsustainedrunsofventriculartachycardia.Thetablebelowcontainstheinvestigationresults.
pH 7.29
pO2 8.1kPa
pCO2 4.9kPa
HCO3 13mmol/litre
WhichoneofthefollowingisthemostappropriatewaytoinitiallymanagetheshortrunsofVT?
A Normalsalineinfusion
B Magnesiuminfusion
C Amiodaroneinfusion
D Adenosinebolus
E ivSodiumbicarbonate
Explanation
Managementofventriculartachycardia
Whilstmagnesiummaybeausefuloptiontocontrolventriculartachycardia(VT)incasesofseveretricyclic
antidepressant(TCA)overdose,ivsodiumbicarbonateistheinitialtherapyofchoice
IncreasingthepHtotherangeof7.457.55hasbeenshowntodecreasetheQRSinterval,stabilisearrhythmias
andincreasebloodpressure
Othercaseseriesstatethatphenytoinmaybeusefulincorrectingconductiondefectsinthispatientpopulation
ConventionalclassIA,IC,IIandIIIantiarrhythmicagentsshouldbeavoided
20931
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20931
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Question76of295
A72yearoldwomanpresentstotheRapidAccessChestPainClinicwithcentralchestpainwhichcomesonwhensheis
walkingherdogonacoldday,andwhenshecarriesherhooveruptwoflightsofstairsathometodothecleaning.Her
episodesofpainhaveworsenedconsiderablyoverthelast2months.Sheisanonsmokerwhohasahistoryof
hypertensionforwhichshetakesramipril5mgdailyandhasType2diabetesforwhichshetakesMetformin1gdaily.On
examinationherBPis135/70mmHg,pulseis80/minandregular.Herchestisclear.
Investigations:
Hb 13.0g/dl
WCC 7.2x109/l
PLT 271x109/l
Na+ 138mmol/l
K+ 4.3mmol/l
Creatinine 110micromol/l
ECG SmallinferiorQwaves,nilelseofnote
Whichofthefollowingisthemostappropriatenextstep?
A Angiography
B ExerciseECG
C Myocardialperfusionscan
D StressECHO
E Startalongactingnitrate
Explanation
TheanswerisAngiography
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NICEguidelinesrecommendthatwhenlikelihoodofcoronaryarterydiseaseis>90%,angiographyisthemost
appropriatenextstepwhenpatientspresentwithrapidlyworseningsymptomsofchestpain.Inthiscase,forawoman
over70whohasriskfactorswithtypicalsymptoms,likelihood>90%shouldbeassumed.Whenestimatedriskisbetween
61and90%,angiographyisalsorecommended.For3060%likelihoodfunctionalimagingshouldtakeplace,andfor10
29%CTcalciumscoring.Assumingstableanginaandprogressingstraighttotherapywithoutinvestigationisnot
recommendedundercurrentguidelines.
https://www.nice.org.uk/guidance/cg95(https://www.nice.org.uk/guidance/cg95)
37802
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Question77of295
A78yearoldmanpresentstotheEmergencyDepartmentwithahistoryofsyncope.AnECGshowscompleteheart
block.
Whichoneofthefollowingphysicalsignsisconsistentwiththediagnosis?
A CannonawavesonJVPatregularintervals
B Softfirstheartsound
C Lowvolumepulse
D Basalsystolicmurmur
E Loudsecondheartsound
Explanation
TheanswerisBasalsystolicmurmur
Completeheartblock
Completeheartblockproducesaslow,regularpulse(2550bpm)thatdoesnotvarywithexercise
Usually,thereisacompensatoryincreaseinstrokevolumewithalargevolumepulseandsystolicflowmurmurs
Cannonawaveshappenwhenatrialcontractioncoincideswithaclosedtricuspidvalve.Whenseen,theirpattern
isirregular
CannonawavesonJVPatregularintervals(OptionA)isincorrect.Cannonawavesoccurirregularlywhenatrial
contractioncoincideswithaclosedtricuspidvalve.
Softfirstheartsound(OptionB)isincorrect.Theintensityofthefirstandsecondheartsoundvariesowingtothelossof
atrioventricularsynchrony.
Lowvolumepulse(OptionC)isincorrect.Acompensationincreaseinstrokevolumemayleadtoasystolicflowmurmur.
Anincreaseinstrokevolumewillleadtoalargervolumepulse.
Loudsecondheartsound(OptionE)isincorrect.Theintensityofthefirstandsecondheartsoundvariesowingtotheloss
ofatrioventricularsynchrony.
41881
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Question78of295
Whichoneofthefollowingischaracteristicofatrialmyxoma?
A Usuallyoriginatesintherightatrium
B Fragmentsoftumoureasilybreakoffandmetastasiseintoperipheralsites
C Echocardiogramisdiagnosticinmostcases
D Theclinicalsignscanmimicseveremitralregurgitation
E Recurrenceisfrequentevenaftersuccessfulsurgicalremovalofthetumour
Explanation
TheanswerisEchocardiogramisdiagnosticinmostcases
Atrialmyxoma
Atrialmyxomaisabenigntumouroftheheart.
Theyaremorecommoninwomenand10%areinherited.
Theclinicalfeaturesarecharacterisedbyatriadof
embolism
intracardiacobstructionmanifestasexertionaldyspnoea,paroxysmalnocturnaldyspnoeaandplatypea
dysnpnoeawhileuprightthatabateswhilesupine.
constitutionalsymptomscough,fever,weightloss,generalmalaise,jointpainsandclubbing.
Twodimensionalechocardiographyisusuallysufficienttomakethediagnosis.Itcanbedistinguishedfromaclot
asaclotistypicallyposteriorlylocatedandhasalayeredappearance.Myxomasaremorelikelytohaveastalkand
befreelymobile.TOEcangivehigherresolutionandMRIorCTcanbeusedifthereisdoubttodistinguishbetween
clotormyxoma.
Usuallyoriginatesintherightatrium(OptionA)isincorrect.Approximately75%originateintheleftatriumitisusually
attachedtotheinteratrialseptum.
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Fragmentsoftumoureasilybreakoffandmetastasiseintoperipheralsites(OptionB)isincorrect.Fragmentsoftumour
easilybreakoffandbehaveasclotstheydonotgrowinitsperipheralsitesanddonotmetastasise.
Theclinicalsignscanmimicseveremitralregurgitation(OptionD)isincorrect.Theclinicalsignscanmimicmitral
stenosis(notregurigitation)andthediastolicmurmurmayvarywithbodyposition(tumourplop).
Recurrenceisfrequentevenaftersuccessfulsurgicalremovalofthetumour(OptionE)isincorrect.Aftercompleteand
carefulremovalofthetumour,recurrenceisveryrare.
41946
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Question79of295
A47yearoldmanwithchestpainof1hdurationisdiagnosedashavingacutemyocardialinfarction.
Whichoneofthefollowingfeatures,ifpresent,wouldbestcontraindicatethrombolytictherapy?
A Bloodpressure160/100mmHg
B Elevatedserumcholesterol
C Historyoflikelyischaemicstrokewithinthepastmonth
D Previousaspirintherapy
E STsegmentelevationinECG
Explanation
TheanswerisHistoryoflikelyischaemicstrokewithinthepastmonth
Thrombolysisinacutemyocardialinfarction
Thereisanapproximate1%riskofstrokeanda0.7%riskofmajorhaemorrhageassociatedwiththeuseof
thrombolysis.
Apriorischaemicstrokewithinthelastyearisanabsolutecontraindicationduetothepotentialforhaemorrhagic
transformation.
Majorcontraindicationsagainsttheuseofthrombolytictherapyare
anyprevioushistoryofhemorrhagicstroke
historyofstroke,dementia,orcentralnervoussystemdamagewithin1year
headtraumaorbrainsurgerywithin6months
knownintracranialneoplasm
suspectedaorticdissection
internalbleedingwithin6weeks
activebleedingorknownbleedingdisorder
majorsurgery,trauma,orbleedingwithin6weeks
traumaticcardiopulmonaryresuscitationwithin3weeks.
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Relativecontraindications
oralanticoagulanttherapy
acutepancreatitis
pregnancyorwithin1weekpostpartum
activepepticulceration
transientischaemicattackwithin6months
dementia
infectiveendocarditis
activecavitatingpulmonarytuberculosis
advancedliverdisease
intracardiacthrombi
uncontrolledhypertension(systolicbloodpressure>180mmHg,diastolicbloodpressure>110mmHg)
punctureofnoncompressiblebloodvesselwithin2weeks
previousstreptokinasetherapy.
Bloodpressure160/100mmHg(OptionA)isincorrect.Thiswouldnotbeacontraindicationtothrombolytictherapy.
Elevatedserumcholesterol(OptionB)isincorrect.Thiswouldnotbeacontraindicationtothrombolytictherapy.
Previousaspirintherapy(OptionD)isincorrect.Thiswouldnotbeacontraindicationtothrombolytictherapy.
STsegmentelevationinECG(OptionE)isincorrect.Thiswouldnotbeacontraindicationtothrombolytictherapy.
41956
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Question80of295
A62yearoldmanpresentstotheEmergencyDepartmentwithpersistentindigestionlikepain,retrosternalinnatureand
radiatingtohisjaw.Heisaheavysmokerofsome40cigarettesperdayandhasbeenpreviouslytreatedforBarretts
oesophagus.Onexaminationheisbradycardicat55bpm,hasabloodpressureof100/50mmHgandlooksunwell.ECG
revealsSTelevationinleadsII,IIIandaVF.
Whatdiagnosisfitsbestwiththisclinicalpicture?
A Acuteanteriormyocardialinfarction
B Inferiormyocardialinfarction
C NonSTelevationmyocardialinfarction
D RecurrenceofBarrettsoesophagus
E Unstableangina
Explanation
TheanswerisInferiormyocardialinfarction
Acutemyocardialinfarction
Inferiormyocardialinfarction(MI)isthecorrectanswer.ThismanhassymptomsandsignsofanacuteMIchanges
intheinferiorleadsonECGtestingconfirmthediagnosisofinferiorMI.
AnteriorMI:LADocclusionSTelevationinV1V4.
LateralMI:LADocclusionSTelevationinV5,V6,aVL.
InferiorMI:RCAocclusionSTelevationinII,III,AVF,reciprocaldepressioninaVL
InferiorMIwithRVinfarction:RCAocclusionSTelevationinII,III,aVF,V1andrightsidedV4lead
(V4R).
PosteriorMI:RCAorLCxocclusion:STdepressioninV1V2,STelevationinposteriorleadsifplaced
(V7V9).
Paininmyocardialinfarction
Myocardialinfarctionissaidtocharacteristicallypresentwithcentralcrushingchestpainradiatingtothe
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armsandjawthatisnotpleuriticincharacter.
However,itisimportanttonotethatlargeinfarctsmaybeassociatedwithalesstypicalpaindistribution,and
upto20%ofMIsmaynotbeassociatedwithpain.
Painlessinfarctsarecommonerintheelderlyandinpatientswithdiabetesmellitus.
Treatment
Acutetreatmentinvolves
oxygentherapy
nitrates
analgesia(includingopiates)
antiplatelets(aspirin,clopidogrelorprasugrelorticagrelor)
earlyprimaryangioplasty.
Earlypostinfarcttreatmentincludestheintroductionofblockadeandangiotensinconvertingenzyme
(ACE)inhibition.
Acuteanteriormyocardialinfarction(OptionA)isincorrect.Thefindingsdescribeddonotmakethisthemostlikely
diagnosis.
NonSTelevationmyocardialinfarction(OptionC)isincorrect.Thefindingsdescribeddonotmakethisthemostlikely
diagnosis.
RecurrenceofBarrettsoesophagus(OptionD)isincorrect.Barrettsoesophagusisahistologicalchange(metaplasia)in
thedistaloesophagusinresponsetorecurrentacidreflux.Barrettsitselfisdiagnosedonoesophagogastroduodenoscopy
(OGD)anddoesnotcausesymptomsthesymptomsarefromtheacidrefluxitself.
Unstableangina(OptionE)isincorrect.UnstableanginalikeNSTEMIbutnotroponinrise.
42008
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Question81of295
A67yearoldwomanpresentswithsyncope.Shehassufferedtwoorthreeepisodesofcollapseduringthepast6months,
themostrecentwhileattendingchurchonaSundaymorning.Shehasahistoryofhypertensionwhichiscurrently
managedwithramiprilandbendroflumethiazideanddyslipidaemiatreatedwithsimvastatin.Onexaminationherpulseis
34bpmandBPis100/50mmHg.Herchestisclearandheartsoundsarenormal.Younoticeirregularcannonwaveson
examinationoftheJVP.Thetablebelowshowstheinvestigationresults.
Hb 12.1g/dl
WCC 7.4109/litre
PLT 203109/litre
Na+ 139mmol/litre
K+ 4.9mmol/litre
Creatinine 149mol/litre
Whichoneofthefollowingisthemostlikelydiagnosis?
A Completeheartblock
B Mobitztype2heartblock
C Sinusbradycardia
D Junctionalrhythm
E Ventricularbigeminy
Explanation
Completeheartblock
Cannonwavesoccurwhentherightatriumcontractsagainstaclosedtricuspidvalve,andtheseoccurirregularly
incompleteheartblock
Thisdiagnosisisentirelyinaccordancewiththepresentationwithbradycardia,relativehypotensionandsyncope
ManagementinthiscasewouldbeanECGtoconfirmthediagnosisandthenlikelyreferralforinsertionof
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permanentpacemaker
Cannonwavesarealsoseeninconjunctionwithventriculartachycardia
21333
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Question82of295
Whichoneofthefollowingstatementsismostaccurateregardingcoarctationoftheaorta?
A Thecoarctationisproximaltotheleftsubclavianarteryoriginiftherightarmbloodpressureissignificantly
higherthanintheleftarm
B Continuousmurmuroverthethoracicspineusuallyoriginatesfromextensivecollaterals
C RibnotchingonplainchestXraycanbeidentifiedasearlyas3monthsafterbirth
D Atrialseptaldefect(ASD)isthecommonestassociatedcongenitalabnormality
E Theriskofbacterialendocarditismeansthatantibioticprophylaxisisrequiredpriortoalldentalprocedures
Explanation
TheanswerisThecoarctationisproximaltotheleftsubclavianarteryoriginiftherightarmbloodpressureis
significantlyhigherthanintheleftarm
Featuresofcoarctationoftheaorta
Thecommonestsiteofdiscreteobstructionoftheaorticlumenisjustdistaltotheoriginoftheleftsubclavian
artery
Thesystolicarterialpressureinthearmsexceedsthatintheleg
However,ifthesystolicarterialpressureintherightarmishigherthanthatoftheleftarmbymorethan30mmHg,
theleftsubclavianisinvolvedinthecoarctation(iecoarctationisproximaltotheoriginofthesubclavianasinthis
case).Thisoccursin15%ofcasesofcoarctation.
Patientswithunrepairedcoarctationareatriskofbacterialendocarditisandshouldbeadvisedaboutthispossibility.
Continuousmurmuroverthethoracicspineusuallyoriginatesfromextensivecollaterals(OptionB)isincorrect.A
continuousmurmuroverthethoracicspineusuallyoriginatesfromsmall,tightcoarctation(<2mm)
RibnotchingonplainchestXraycanbeidentifiedasearlyas3monthsafterbirth(OptionC)isincorrect.Notchingof
theinferiorborderoftheribsfromcollateralvesselsiscommonandusuallymanifestsinadultsandolderchildren,asit
takestimetodevelop.
Atrialseptaldefect(ASD)isthecommonestassociatedcongenitalabnormality(OptionD)isincorrect.Othercardiac
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malformationsarefrequent,thecommonestbeingabicuspidaorticvalve,occurringin50%ofthecoarctations.
Coarctationshouldbethoughtofasanaortopathy,conditionsinwhichthewholeaortaisabnormal.Theaorticvalve,an
aorticstructure,isthereforealsolikelytobeabnormal.
Theriskofbacterialendocarditismeansthatantibioticprophylaxisisrequiredpriortoalldentalprocedures(OptionE)is
incorrect.Antibioticprophylaxisisnolongeradvisedorgiven,sincetheNICEguidelineschangedin2008.Thisisnot
effectiveinreducingtherisksofinfectionfollowingdentalorotherprocedures.
41945
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Question83of295
A64yearoldwomanpresentswithanepisodeofsyncopewhileoutshopping.Onmoredirectquestioningshealso
reportsafewepisodesoffastregularpalpitations,whichsheisabletotapoutonherhand.Sheisdischargedtoawaitan
outpatient24hECGHolterrecording.Unfortunatelysheisreadmittedaftersufferingafitwhileinbed,herhusbandfelt
herpulseatthetimeandclaimsthatshewaspulselessforafewseconds.
Whatdiagnosisfitsbestwiththisclinicalpicture?
A Atrialflutter
B Epilepsy
C Multipletransientischaemicattacks
D Paroxysmalatrialfibrillation
E Sicksinussyndrome
Explanation
TheanswerisSicksinussyndrome
Sicksinussyndromeischaracterisedby
periodsofsinusbradycardia
sinusarrest
acombinationofsinoatrialoratrioventricularconductiondefectsosupraventriculartachycardiascausing
regularfastheartrates.
Thecauseisfibrosisorfattyinfiltrationofthesinusnode,atrioventricularnode,Hisbundle,oritsbranches.
Inadultsthediseaseisoftenassociatedwithatherosclerosis,butmayoccurinthepresenceofanormalheart.
Presentationmaybewithlightheadedness,syncopeorpalpitations.
WorkupincludesECGandambulatorycardiacrhythmmonitoring.
Drugtreatmentaloneoftachyarrhythmiasmayresultinanincreasedriskofheartblock(eggivingblockerstolimit
theSVTwillaggravatepauses).
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Apermanentpacemakeristhetreatmentofchoicethepacemakerwillpreventthecardiacpausesandenable
maximummedicaltherapyoftheSVTs(anybradycardiatriggeredbytheblockerswillbeprotectedbythe
pacemaker).
Atrialflutter(OptionA)isincorrect.Inatrialflutter,patientshavelongsustainedperiodsofarrhythmia.Thepulseisoften
irregularbecausetheblockistypicallyvariable.
Epilepsy(OptionB)isincorrect.Epilepsymayexplainthefithowever,thehusbandnotedtherewasnopulse.Itismore
likelythatthefitwasaconsequenceofcerebralanoxiaduetoacardiacpause.Thereforesicksinussyndromeismore
likely.
Multipletransientischaemicattacks(TIAs)(OptionC)isincorrect.MultipleTIAsareunlikelyastheydonotexplainthe
fastregularheartbeatandarenotassociatedwithlossofconsciousness.
Paroxysmalatrialfibrillation(AF)(OptionD)isincorrect.InparoxysmalAFpatientshaveirregularpalpitationswith
symptomsthatcomeandgo.Althoughtheymayhavecardiacpauses,thisdoesnotfitthescenariopresented.
42004
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Question84of295
Apatientwithleftventricularfailureundergoesechocardiography.
Whichoneofthefollowingisthecorrectformulaforcalculatingtheejectionfraction(EF)?
A EF=[enddiastolicvolume(EDV)endsystolicvolume(ESV)]/EDV
B EF=[enddiastolicvolume(EDV)endsystolicvolume(ESV)]/heartrate(HR)
C EF=[heartrate(HR)enddiastolicvolume(EDV)]/endsystolicvolume(ESV)
D EF=[heartrate(HR)endsystolicvolume(ESV)]/enddiastolicvolume(EDV)
E EF=[endsystolicvolume(ESV)enddiastolicvolume(EDV)]/EDV
Explanation
Ejectionfraction(EF)iscalculatedusingthefollowingequation:
EF=[enddiastolicvolume(EDV)endsystolicvolume(ESV)]/EDV
Inessenceitisthedifferenceinthevolumeofthevolumebetweenwhentheventricleisfullofblood,(endofdiastole),vs
whenitismostemptyofblood,(thenendofsystole),expressedasapercentage.Normalindividualsusuallyhavean
ejectionfractionbetween50%and65%.
5488
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Question85of295
Ina36yearoldpatientwithhypertrophiccardiomyopathywhohashadaventricularfibrillationarrest,whichoneofthe
followingislikelytoimproveprognosis?
A Betablocker
B ImplantedDCfibrillator
C Pacemaker
D Surgicalmyotomy
E Verapamil
Explanation
TheanswerisImplantedDCfibrillator
HypertrophiccardiomyopathyPatientswithhypertrophiccardiomyopathy(HCM)areathighriskofarrhythmogenic
events.Patientswithaconfirmedepisodeoflifethreateningarrhythmia(VForsustainedVT),shouldhavean
implanteddefibrillator.Thiswillmonitorforotherepisodesoftachycardiaand,ifwithindefinedtreatmentzones,
willeitherattempttoperformantitachycardiapacing(togaincontroloverthearrhythmiaandgraduallyslowit
down)oritwillperformDCdefibrillation.TheotheroptionsareallestablishedtherapiesforHCMbutarefor
symptomaticimprovementanddonotimproveprognosisinapatientwithconfirmedVF.
HCM
Hypertrophiccardiomyopathyisdiagnosedbyechocardiography.
Asymmetricalseptalhypertrophy,systolicanteriormotionofthemitralvalveandmitralregurgitationareall
features.
Angina,palpitations,dyspnoeaandsuddendeathoccur.
Improvementofventricularfunctionwithablocker,verapamiloramiodaronemayhelpsymptoms.
Amiodaronemayhelppreventarrhythmiasandsuddendeath.
Dualchamberpacingmayhelpdrugresistantsymptomsbycausingdepolarisationfromtherightventricular
apex,resultinginalteredmotionoftheintraventricularseptumandadiminishedsubaorticgradient(thisis
theoppositeofresynchronisationpacingdeliberatedssynchronyisbeinginducedtoreducetheleft
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ventriculargradient).
Animplantedcardiacdefibrillatorwillimprovetheprognosisofpatientswhohavehadanepisodeoffailed
suddendeathorsymptomaticventriculartachyarrhythmiabytreatinganyfuturesuchepisodes.
Antiarrhythmicdrugtherapyshouldbecontinued,toreducetherequirementforimplantablecardioverter
defibrillator(ICD)therapies.
Betablocker(OptionA)isincorrect.AsdescribedBetablockermayimprovesymptomsbutwillnotofferanimproved
prognosis.
Pacemaker(OptionC)isincorrect.Asdescribedapacemakerwillproducesymptomaticimprovementbutwillnot
improveprognosis.
Surgicalmyotomy(OptionD)isincorrect.Surgicaldebulkingoftheseptalmuscle(myotomy)mayhelpsymptomrelief
butwillnotalterthenaturalhistoryofthedisease.
Verapamil(OptionE)isincorrect.Asdescribedverapamilwouldnotimproveprognosishere.
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Question86of295
Whichoneofthefollowingisthebestclinicalmarkeroftheseverityofaorticstenosis?
A Characterofapexbeat
B Characterofcarotidpulse
C CharacterofS2
D Intensityofmurmur
E Pulserate
Explanation
Aorticstenosis
Physicalfindingsofaorticstenosismayincludeanarrowpulsepressure,especiallywhenstrokevolume
decreases,andaslowrising,smallvolumecarotidpulse
However,thepoorlycompliantarterialwallmaymasktheseabnormalities,sothatthecarotidpulseappears
relativelynormal
Thecardiacapeximpulseisforcefulandsustained,butthisfindingmaybemaskedbykyphosis(inwhichthe
anteroposteriordiameterofthechestisincreased)
Heartsounds
Thefirstheartsoundissoft
Theaorticcomponentofthesecondheartsoundisalsosoftitmaybeinaudiblewhenstenosisissevereandthe
valveisheavilycalcified
Reversesplittingofthesecondheartsoundmayoccurinpatientswithleftventricularfailure
Afourthheartsoundiscommonbutdisappearsinonequarterofelderlypatientswhodevelopatrialfibrillation
Ejectionsoundsarerarebecausethevalvecuspsareimmobile
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Question87of295
A20yearoldmanattendstheEmergencyDepartmentwithpalpitationsdescribedasregularrapidbeatingoftheheart.
AnECGshowsaregularrhythmwitharateof200bpmandaQRSdurationof80ms.Thetachycardiaspontaneously
resolves.AnECGinsinusrhythmrevealsaPRintervalof60msandaQRSdurationof120ms,withapositivedeltain
V1.
Whichoneofthefollowingstatementsistrueregardingthismanstachycardia?
A Carotidsinusmassagewillbeineffective
B Intravenousadenosineisofnouse
C Digoxinshouldbeusedasaprophylacticagent
D Verapamiliscontraindicated
E Atrialfibrillationiswelltoleratedinsuchpatients
Explanation
TheanswerisVerapamiliscontraindicated
Verapamiliscontraindicatedasitincreasesconductioninthebypasstractthisincreasestheriskofrapidconduction
ofanatrialarrhythmiaalongtheaccessorypathwayandpotentialventriculararrhythmias.
ThismanhastypeAWolffParkinsonWhite(WPW)syndrome,inwhichanabnormalbandofatrialtissueconnects
theatriatotheventricle,bypassingtheatrioventricular(AV)node.
AstheAVnodeandbypasstracthavedifferentconductionspeedsandrefractoryperiods,areentrycircuitcanbe
formedthatresultsintachycardia.
WPWpatientstypicallyhaveashortenedPRinterval,andhaveadeltawavewithprolongationoftheQRScomplex.
Prophylacticdrugtherapyisindicatedforsymptomaticpatients.Agentsusedinanattempttoslowtheconduction
rateandprolongtherefractoryperiodofthebypasstractare
flecainide
disopyramide
amiodarone
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Carotidsinusmassagewillbeineffective(OptionA)isincorrect.Carotidsinusmassagewilloftenterminateanepisodeof
tachycardia.
Intravenousadenosineisofnouse(OptionB)isincorrect.IVadenosinewilloftenterminateanepisodeoftachycardia.
AdenosineisusuallyavoidedbecauseoftheriskofprecipitatingVFinasmallpercentageofpatientswithWPWthis
occurspredominantlyinpatientswithanaccessorypathwayandatrialfibrillationoranotheratrialarrhythmia.Giving
adenosinemayselectivelyblocktheAVnodebutnottheaccessorypathwaysincethislackstheratelimitingpropertiesof
theAVnode.Thiswouldallowrapidconductionoftheatrialarrhythmiaalongtheaccessorypathwaythiscouldtrigger
ventricularfibrillation.
Digoxinshouldbeusedasaprophylacticagent(OptionC)isincorrect.Digoxiniscontraindicatedasitincreases
conductioninthebypasstractthisincreasestheriskofrapidconductionofanatrialarrhythmiaalongtheaccessory
pathwayandpotentialventriculararrhythmias.
Atrialfibrillationiswelltoleratedinsuchpatients(OptionE)isincorrect.ThepresenceofAFinpatientswithWPW
shouldbetreatedasamedicalemergencywithDCcardioversion.
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Question88of295
A30yearoldwomanpresentswithpleuriticchestpainandhaemoptysis.Herbloodpressureisstableat130/80mmHg.A
CTpulmonaryangiogram(CTPA)showsevidenceofbilateralbasalpulmonaryemboli.ThereisnoevidenceofRV
dysfunction,clinicallyandonechocardiography.
Inadditiontooxygen,whichoneofthefollowingistheappropriatemanagementforthispatient?
A Heparinandconsiderationforsurgery
B Heparinandanalgesia
C Heparinplusmechanicalintervention
D Heparinplusthrombolytictherapy
E Supportive
Explanation
TheanswerisHeparinandanalgesia
Thispatienthaspotentiallyhaduptotwosmalltomoderatepulmonaryembolisms(PEs),probablyassociatedwith
pulmonaryinfarction.
Themanagementinthiscasewouldbeheparinandsimpleanalgesicstocontrolherchestpain.Heparinshouldbe
weightadjustedandthenwarfarinshouldbestartedforatleast36months.
Ifthereweresignsofalarge/massivePE(hypotension,rightventriculardysfunction),theidealmanagementwould
includethrombolytictherapyormechanicalintervention(egcatheterinsertionintothepulmonaryvesselsto
physicallybreakdowntheclot).
Heparinandconsiderationforsurgery(OptionA)isincorrect.Asdescribedthiswouldnotbethemostappropriate
management.
Heparinplusmechanicalintervention(OptionC)isincorrect.Asdescribedthiswouldnotbethemostappropriate
management.
Heparinplusthrombolytictherapy(OptionD)isincorrect.Asdescribedthiswouldnotbethemostappropriate
management.
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Supportive(OptionE)isincorrect.Asdescribedthiswouldnotbethemostappropriatemanagement.
41928
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Question89of295
A70yearoldmanwithahistoryofextensiveacutemyocardialinfarction4yearsearlier,comestothehospitalwithhis
wife.Hehassufferedfourepisodesofcollapseoverthepast6months,themostrecentthatmorning,whenhiswife
witnessedslurredspeech,confusionandweaknessofhisrightarmandleg.Onexaminationhehasnochestpain,hisBPis
145/82mmHgandheisnotincardiacfailure.Hisapexbeatisdisplacedtotheleft.Theneurologicalfeatureshave
resolved.Thetablebelowshowstheinvestigationresults.
Hb 12.1g/dl
WCC 5.9109/litre
PLT 187109/litre
Na+ 142mmol/litre
K+ 5.1mmol/litre
Creatinine 148mol/lotre
ECG STelevationintheanteriorleads
Troponin(hs) <lowerlimitofquantification
Whichoneofthefollowingisthemostappropriatewaytodiagnosehisprimaryunderlyingpathology?
A MonitorontheCCU
B ThrombolysewithtPA
C ReferforimmediatePCI
D ArrangeanurgentCThead
E ArrangeacardiacMRI
Explanation
Diagnosisofananeurysm
PersistentSTelevationintheabsenceofchestpain,inapatientwhohasahistoryofpreviousanteriormyocardial
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infarctionraisesthepossibilityofleftventricularaneurysm
CardiacMRIisaneffectivewaytoimagetheaneurysmnoninvasively,andwouldbethepreferredinitial
investigation
Thepresenceofmultipletransientischaemicattacksraisesthepossibilityofthrombusformation
Henceanticoagulationmaybeconsideredhere,withpossiblereferralforsurgicalexcisionofaneurysm
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Question90of295
A63yearoldmanwithknownchronicheartfailureisadmittedwithsymptomsatrest.Examinationrevealspitting
oedematohisknees,elevatedjugularvenouspressureandbasalcrepitations.Heisinsinusrhythmatarateof80bpmand
hisbloodpressureis100/60mmHg.Currentmedicationincludesbisoprolol10mgoncedaily,frusemide80mgonce
dailyandramipril2.5mgtwicedaily.Bloodtestsrevealasodiumconcentrationof133mmol/litre,potassium4.9
mmol/litreandcreatinineof169mol/litre.Theadmittingdoctorcommenceshimonivfrusemide80mgtwicedailyand
increaseshisramiprilto5mgtwicedaily.Whenyoureviewhimthefollowingdaywhatotherdrugwouldbemost
appropriatetoinclude?
A Amiloride5mgod
B Bendrofluazide2.5mgod
C Bumetanide2mgbd
D Metolazone5mgod
E Spironolactone25mgod
Explanation
Managementofdecompensatedchronicheartfailure
ThismanhasdecompensatedCHFwithsymptomsatrest(NewYorkHeartAssociationclassIV)
Examinationhasrevealedsignificantfluidretention
Theinitialmanagementplanofchangingtoivfrusemideissensiblesincecoexistentgutwalloedemaislikelyto
impingeonoralabsorption,andincreasingramipril,avasodilator,isalsoasensibleapproach
Theadditionofathiazide(inhibitingsodiumreabsorptionindistaltubule)mayworkinsynergywithaloop
diureticthesameistrueformetolazone
Spironolactone,analdosteroneantagonist,hasbeenshowntoimprovethemortalityrateandsymptomsandreduce
hospitalisationinpatientswithsevereCHFalreadyonconventionaltreatment
Benefitsareinadditiontoitsdiureticeffectsincealdosteroneitselfhasadverseeffectsonmyocardialstructure
andfunction
Clearly,carefulmonitoringofrenalfunctionandbiochemistryisimportantinsuchpatients
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Question91of295
WhichoneofthefollowingantiarrhythmicagentsworksprimarilybyitsactiononSAandAVnodes?
A Amiodarone
B Atenolol
C Flecainide
D Sotalol
E Verapamil
Explanation
TheanswerisVerapamil
Calciumchannelblockers(classIVagents)actmainlyonthesinoatrial(SA)andatrioventricular(AV)nodes(direct
membraneeffect),asthesestructuresarealmostexclusivelydepolarisedbytheslowcalciumchannels.Theyalso
reducecontractilityoftheheartandsorequirecautioninheartfailure.
Amiodarone(OptionA)isincorrect.Amiodarone(likesotalol)isaclassIIIagent.ClassIIIagentsarepredominantly
potassiumchannelinhibitors,whichprolongrepolorisationthismeansactionpotentialdurationisprolongedand
thereforetherefractoryperiods.Theyhavelittleeffectonconductionvelocity.Thismeanstheyarehelpfulinreentrant
arrhythmias.
Atenolol(OptionB)isincorrect.Atenololandotherblockers(classIIagents)actbyblockingtheeffectsof
catecholamineson1adrenergicreceptors,whichreducessympatheticactivityontheheart.Byslowingconduction
throughtheAVnodetheyareparticularlyusefulincontrollingSVTsbutalsoimpairthenormalhomeostatic
mechanismsdesignedtocontrolheartrateandcontractility.Therefore,theyimpairthenormalresponsestobloodlossor
hypoglycaemia.Incontrast,calciumchannelantagonistsarelesslikelytodothis.
Flecainide(OptionC)isincorrect.Flecainideisasodiumchannelblocker(Nav1.5sodiumchannelclassIcagent)and
decreasesthespeedofdepolarisation(itslowstheupstrokeoftheactionpotentialand,therefore,decreasesconduction
velocity).ItsgreatesteffectisontheHisPurkinjesystemandtheventricularmyocardium.Itisusedependent,havingthe
greatesteffectasheartrateincreases.Itselectivelyincreasestherefactorinessofantegradeandretrogradepathways,
makingitidealtotreatSVTswithoutcausingadversebradycardia.Ithasexcellentbioavailabilityafterevenanoraldose.
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Sotalol(OptionD)isincorrect.Sotalol(likeamiodarone)isaclassIIIagent.ClassIIIagentsarepredominantly
potassiumchannelinhibitors,whichprolongrepolorisationthismeansactionpotentialdurationisprolongedand
thereforetherefractoryperiods.Theyhavelittleeffectonconductionvelocity.Thismeanstheyarehelpfulinreentrant
arrhythmias.
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Question92of295
A67yearoldwomanisfoundtohaveasmallpericardialeffusionlocatedposteriorlyonroutineechocardiography.There
isnohaemodynamiccompromise,shehasnopastmedicalhistoryofnote.
Whichoneofthefollowingisthemostappropriatenextstepinhermanagement?
A Diagnostictap
B Mammography
C Tuberculosisscreen
D Reassure
E Rightheartcatheterexamination
Explanation
Pericardialeffusion
Oncethediagnosisofpericardialeffusionhasbeenmade,itisimportanttodeterminewhethertheeffusionis
creatingsignificanthaemodynamiccompromise
Asymptomaticpatientswithouthaemodynamiccompromise,evenwithlargepericardialeffusions,donotneedto
betreatedwithpericardiocentesisunlessthereisaneedforfluidanalysisfordiagnosticpurposes(eg,inacute
bacterialpericarditis,tuberculosisandneoplasias)
AprevioushistoryofTBorhistoryofTBexposuremaypromptscreeningforthepresenceofactivedisease
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Question93of295
A35yearoldwomangivesahistoryofprogressiveexertionaldyspnoeaandfatigueoverthelastyear.Examination
revealsfeaturesofrightsidedheartfailurewithpulmonaryhypertension,buttherearenocracklestosuggestfibrosis.
Pulmonaryfunctiontestingrulesoutobstructiveairwaysdisease.Lungperfusionscanningandpulmonaryangiography
failtodetectpulmonarythromboembolicdisease.Anechocardiogramshowsenlargedrightheartchambers.ANCAand
HIVtestingarenegative.
Whichoneofthefollowingisthelikelydiagnosis?
A Pulmonaryvasculitis
B Mitralvalveprolapse
C Idiopathicpulmonaryarterialhypertension
D Mitralstenosis
E Dilatedcardiomyopathy
Explanation
TheanswerisIdiopathicpulmonaryarterialhypertension
Thesymptoms,signsandechocardiographicfeaturesareconsistentwithpulmonaryhypertension.Thenegative
investigationssuggestthatthelikelydiagnosisispulmonaryarterialhypertension(primaryoridiopathicpulmonary
hypertension).
Pulmonaryhypertension
Pulmonaryhypertensionisahaemodynamicandpathophysiologicalstatethatisfoundinmultipleclinical
conditions
Itischaracterisedbyameanpulmonaryarterypressure(PAP)25mmHgonrightheartcatheterisation
Themostrecentclinicalclassificationofpulmonaryhypertension(DanaPoint,2008)dividesitupintofivegroups
Itisessentialtodifferentiatethetermpulmonaryhypertension(PH),whichreferstoanelevationinthemean
pulmonaryarterypressure,fromthetermpulmonaryarterialhypertension(PAH),whichreferstoaclinical
conditioncharacterisedbyprecapillarypulmonaryhypertensionintheabsenceofothercauses
Pulmonaryarterialhypertension(WHOGroup1)
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Pulmonaryarterialhypertensionisaclinicalconditioncharacterisedbyprecapillarypulmonaryhypertension(ie
withalowpulmonarywedgepressure<15mmHg)intheabsenceofanyotherpossiblecauseofsimilar
haemodynamicabnormalities
Othertextsmayrefertoitasprimaryoridiopathicpulmonaryhypertension
Pulmonaryarterialhypertensionsecondarytocongenitalshuntsisincludedinthiscategory
Pulmonaryhypertensionduetoothercauses
WHOGroup2:Leftheartdisease
Fromleftventriculardysfunctionorvalvulardisease
WHOGroup3:Lungdiseaseorhypoxia
ChroniclungdiseasesuchasCOPDorILDthatleadtovasoconstrictionduetochronichypoxia
WHOGroup4:Chronicthromboembolicpulmonaryhypertension
Frompulmonarythromboembolicdisease
WHOGroup5:Unclearormultifactorialmechanisms
Pulmonaryvasculitis(OptionA)isincorrect.Itcanalsobeassociatedwithvasculitis,butthispatienthasanormal
ANCA.
Mitralvalveprolapse(OptionB)isincorrect.Pulmonaryhypertensioncanbecausedbyleftheartdisease,butthiswasnot
foundonechocardiographyofthispatient.
Mitralstenosis(OptionD)isincorrect.Pulmonaryhypertensioncanbecausedbyleftheartdisease,butthiswasnotfound
onechocardiographyofthispatient.
Dilatedcardiomyopathy(OptionE)isincorrect.Pulmonaryhypertensioncanbecausedbyleftheartdisease,butthiswas
notfoundonechocardiographyofthispatient.
41880
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Question94of295
A72yearoldmanwasadmittedwithanacuteanteriormyocardialinfarction.Hehaschronicrenalimpairment,witha
recentcreatininerecordedat148mol/litre.Medicationincludedramipril,atorvastatinandindapamideforthetreatment
ofhypertension.Hewastakenstraighttotheangiographysuitewherehereceivedstentingofaleftmainstemstenosis.
Youareaskedtoseehimafterabout30hoursasthenursesfeelheisdeteriorating.OnexaminationhisBPis149/84
mmHg,hispulseis75bpmandregular.Hislegslookduskyincolour,particularlyhisrightbigtoewhichlooksbluein
colour.Hehassplinterhaemorrhagesaffectingtoenailsonbothfeet.Thereisaloudleftfemoralbruit.Thetablebelow
containstheinvestigationresults.
Hb 13.2g/dl
WCC 5.0109/litre
PLT 190109/litre
Na+ 141mmol/litre
K+ 5.9mmol/litre
Creatinine 630mol/litre
Urine blood++,protein+
Whichoneofthefollowingisthemostlikelydiagnosis?
A Renalveinthrombosis
B Acutetubularnecrosis
C Renalarterystenosis
D Cholesterolembolism
E Femoralarteryembolism
Explanation
Cholesterolembolism
Riskfactorsforcholesterolembolismaftercoronaryarteryinstrumentationincludeincreasedage(>60years),
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hypertension,cerebralvasculardiseaseandaortoiliacarterialdisease
Management
Furthervascularprocedures,anticoagulantandthrombolytictherapiesarenotofvalueinthemanagementofthe
condition
Patientsshouldbedialysedduringtheacuteperiodastheymayrecoveralimitedamountofrenalfunction
Prognosis
Unfortunatelytheprognosisofcholesterolembolismisverypoor:wheremultipleorgansareinvolvedmortality
mayapproach90%at3months
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Question95of295
A49yearoldmanisnotedtohaveshorteningoftheQTintervalontheECG.
Whichdrugismostlikelytoberesponsible?
A Amiodarone
B Atenolol
C Digoxin
D Flecainide
E Sotalol
Explanation
TheanswerisDigoxin
EffectofdrugsontheQTinterval
Thecardiacglycosides(digoxinandouabain)shortentheQTinterval.Therefore,digoxinisthecorrectanswer.
ClassIa(egdisopyramide),classIc(egflecainide)andclassIIIdrugs(egamiodaroneandsotalol)allprolongthe
QTinterval(henceareallincorrectanswers).
BetablockershaveaneutraleffectontheQTintervalbutareeffectiveatstabilisingtheQTinlongQTsyndromes
(theyareusedasatreatmentforlongQT).
MorecommonquestionslookforcausesofalongQT:
CausesofaprolongedQTc(>440ms)are:
hypokalaemia
hypomagnesaemia
hypocalcaemia
hypothermia
myocardialischaemia
postcardiacarrest
raisedintracranialpressure
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congenitallongQTsyndrome.
Drugsare:Antiarrhythmics(flecainide,sotalol,amiodarone),antipsychotics(haloperidol,quetiapine,olanzapine),
TCAs(amitriptyline),antidepressants(citalopram,venlafaxine),antihistamines(terfanadine,loratidine),antibiotics
(erythromycin,clarithromycin).
Amiodarone(OptionA)isincorrect.Amiodarone,aclassIIIdrugprolongstheQTinterval.
Atenolol(OptionB)isincorrect.AsdescribedbetablockershaveaneutraleffectontheQTinterval.
Flecainide(OptionD)isincorrect.Flecainide,aclassIcdrugprolongstheQTinterval.
Sotalol(OptionE)isincorrect.Sotalol,aclassIIIdrugprolongstheQTinterval.
41982
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Question96of295
A32yearoldwomanwhoisknowntobe17weekspregnantpresentsforreview.Shehasperiodsofparoxysmal
supraventriculartachycardia(SVT)andonthisoccasionhasaventricularrateof165bpmandabloodpressureof105/50
mmHg,andisfeelingfaintandunwell.
Whichoneofthefollowingantiarrhythmicswouldbethemostappropriateprophylaxisforher?
A Amiodarone
B Digoxin
C Metoprolol
D Phenytoin
E Propafenone
Explanation
TheanswerisMetoprolol
Paroxysmalsupraventriculartachycardia
Thispatienthasparoxysmalsupraventriculartachycardia(SVT).
GuidelinessuggestthatmetoprololispotentiallythemostappropriateoptionforSVTinpregnancy
thereforethisisthebestanswer.ItisashortactingblockerandaTDSregimenisrequired.
Amiodarone(OptionA)isincorrect.Amiodaroneisknowntobeteratogenicandiscontraindicatedinpregnancy.
Digoxin(OptionB)isincorrect.Althoughdigoxinslowstheventricularrateinpatientswithchronicatrialfibrillation,it
doesnotmaintainsinusrhythminpatientswithparoxysmaltachycardia.
Phenytoin(OptionD)isincorrect.Phenytoinhasnoroleinarrhythmiamanagementandisaknownteratogen.
Propafenone(OptionE)isincorrect.Propafenoneisnotthebestoptionhereforapregnantpatient.
42019
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Question97of295
A72yearoldmanwasdischargedfollowingsuccessfulprostheticaorticvalvereplacement.ApartfromasmallVenflon
abscess,whichhealedwithappropriatedressingsandcannularemoval,hisprogresshadbeenunremarkable.Now,some6
weekslater,heisbroughttotheEmergencyDepartmentbyhiswife,sufferingfrommalaise,feverandnightsweats.On
examinationyoucanhearanormalS1withanejectionsystolicmurmurandametallicsoundingS2.Bloodtestingreveals
mildanaemiaandraisedCRP.Transoesophagealechocardiographyshowssomedehiscenceoftheaorticvalve
replacement.
Whichoneofthefollowingregimensisthemostappropriateinitialchoiceofantibiotictherapy?
A Intravenousgentamicinandvancomycin
B Intravenousgentamicintherapy
C Intravenouspenicillinandgentamicin
D Intravenouspenicillintherapy
E Intravenousvancomycin,gentamicinandoralrifampicin
Explanation
TheanswerisIntravenousvancomycin,gentamicinandoralrifampicin
Thispatientpresentswithsignsofinfectionintheearlyphaseafteraorticvalvereplacement.Theyshouldbetreated
asinfectiveendocarditisoftheprostheticvalveuntilprovenotherwise.Bothcardiologistsandcardiothoracic
surgeonsshouldbealertedimmediatelyandantibioticsstartedpromptly,onceatleastthreesetsofbloodcultures
havebeentaken.
Thechoiceofantibioticstotreatendocarditisshouldbeguidedbylocalpolicy,butinthecaseofpossible
prostheticvalveendocarditis,intravenousvancomycin,gentamicinandoralrifampicinisthemost
appropriateregimethisisbecauseearlyprostheticvalveendocarditisisusuallycausedbyaStaphylococcus
andthisoptionincludesvancomycintoprovideoptimalcover.
Staphyloccusepidermidisisthemostcommonorganisiminearlyprostheticvalveendocarditisit
proliferatesonthevalveandstitchesafterenteringthebodyinthepostoperativephaseviaintravenouslines.
Ittypicallymanifestswithin2monthsofsurgery,butmoreindolentvariantscouldpresentlater.
OthercausativeorganismsincludeStaphylococcusaureus,Gramnegativebacilli,diphtheroidsandCandida
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speciestheseareallmorelikelytopresentveryearly.
Inpatientswithprostheticvalves,transthoracicechocardiographyislesssensitivethantransoesophageal
echofordetectingvalveabnormalities.Notethatsignscanbesubtle,suchasdestructionofthestitchesfor
thesewingringofthevalve.
Unfortunately,medicaltherapyisrarelysuccessfulinprostheticvalveendocarditis,andsurgicalvalve
replacementunderantibioticcoverisusuallyrequired.
Intravenousgentamicinandvancomycin(OptionA)isincorrect.Asdescribedthisisnotthemostappropriateantibiotic
regimeinthisinstance.
Intravenousgentamicintherapy(OptionB)isincorrect.Asdescribedthisisnotthemostappropriateantibioticregimein
thisinstance.
Intravenouspenicillinandgentamicin(OptionC)isincorrect.Intravenouspenicillinandgentamicinisthemost
appropriateinitialtherapyfornonprostheticvalveendocarditisandshouldbeusedearlyuntilorganismsandsensitivities
areknown.
Intravenouspenicillintherapy(OptionD)isincorrect.Asdescribedthisisnotthemostappropriateantibioticregimein
thisinstance.
42017
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Question98of295
An18yearoldyoungmanpresentstotheEmergencyDepartmenthavingdevelopedpalpitationswhileplayingfootball.
ECGshowsrapidatrialfibrillationwithaventricularrateofaround250bpm.QRSdurationisprolongedataround130
ms.DCcardioversionisperformed.SubsequentECGinsinusrhythmdemonstratesaPRintervalof100ms,positiveR
waveinV1andthepresenceofadeltawave.
Whatfurthertreatmentwouldyourecommend?
A Atrialdefibrillatorimplantation
B Intravenousandthenoralloadingwithamiodarone
C Radiofrequencyablationoftheaccessorypathway
D RadiofrequencyablationoftheAVnode
E Surgicalablationoftheaccessorypathway
Explanation
ArrhythmiasassociatedwithWolffParkinsonWhitesyndrome
ThisyoungmanhasWolffParkinsonWhite(WPW)syndrome
Themostcommonarrhythmiaisanatrioventricularreentrytachycardia(AVRT)
ThisisanarrowcomplexwithanterogradeconductionthroughtheAVnodeandretrogradeconductionviathe
accessorypathway
Patientswhodevelopatrialfibrillationareatriskofrapidanterogradeconductiontotheventriclesviathe
accessorypathway,andthismaysubsequentlydegeneratetoventricularfibrillation
TheextremelyrapidconductionwithbroadQRSdurationistypicalofthiscomplication
Radiofrequencyablationoftheaccessorypathwayisrecommendedinthissettingandispotentiallycurative
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Question99of295
Whatisthefirstlinetreatmentfora50yearoldmanwithknownpoorleftventricularfunction,whopresentswithabroad
complextachycardiaatarateof150bpmandabloodpressureof120/70mmHg?
A Amiodarone
B Betablockers
C Flecainide
D Lidocaine
E Verapamil
Explanation
TheanswerisAmiodarone
Overall,byaprocessofeliminationandbyfollowingtheALSguidelines,amiodaroneisthemostappropriate
choice.
Treatingventriculartachycardia
Inthepresenceofpoorleftventricularfunction,abroadcomplextachycardiaishighlylikelytobe
ventriculartachycardia(VT).
VT,ifhaemodynamicallycompromised,mustbetreatedwithimmediateDCcardioversion.
Ifthebloodpressureismaintained,medicaltherapycanbetried.
Amiodaroneistypicallyfirstlineandthereforeisthecorrectanswer.Itshouldbegivenintravenouslyand
shouldbegivenviaacentrallineduetotheriskofextravasationandconsequenttissuedamage.
Betablockers(OptionB)isincorrect.BetablockersmayalreadybebeingusedinapatientwithsevereLVdysfunction
andmaybeusedtoreducecardiacdemand,therebyreducingthelikelihoodoffutureVThowever,intheacutesituation,
theyarenotusedfirstline.
Flecainide(OptionC)isincorrect.Flecainideshouldbeavoidedinpatientswithpriormyocardialinfarctionorstructural
heartdiseasethatisthecaseinthispatient,asheisknowntohavepoorLVfunction.Flecainidecanrarelycause
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degenerationofstableVTtoVF,andthereforeisnotthecorrectanswerhere.
Lidocaine(OptionD)isincorrect.Ifamiodaronefails,lidocaineisusedassecondline.However,giventhepoorLV
function,cautionisrequired.Lidocaineisthereforeincorrect.
Verapamil(OptionE)isincorrect.Verapamil,whichisverynegativelyinotropic,willprecipitatecirculatorycollapsein
VTandisthereforecontraindicated.
41987
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Question100of295
A25yearoldmedicalstudentnoticedthathehadamurmurwhenhetestedhisnewstethoscope.Onassessmentinthe
CardiologyClinic,hewasfoundtohaveaharshsystolicmurmuroverhisprecordium,whichdidnotchangewith
inspiration.ECGshowedfeaturesofbiventricularhypertrophy.
Whatisthemostlikelydiagnosis?
A Aorticstenosis
B Hypertrophiccardiomyopathy
C Mitralregurgitation
D Tricuspidregurgitation
E Ventricularseptaldefect
Explanation
TheanswerisVentricularseptaldefect
Rightsidedmurmursincreasewithinspiration(egtricuspidregurgitation(TR)),whereasleftsidedmurmursdonot
increasewithinspiration.
ThecluetodiagnosisisintheECGfinding:aorticstenosisandmitralregurgitationproduceleftventricular
hypertrophy(LVH),TRproducesrightventricularhypertrophy(RVH)andaventricularseptaldefect(VSD)
producesbiventricularhypertrophy(henceEisthecorrectanswer).
BiventricularhypertrophyisclassicallydescribedashavingbiphasicQRScomplexesinV25whichisknownas
theKatzWachtelphenomenonandisclassicforVSD.
Inothercases,biventricularhypertrophyonanECGconsistsoffeaturesofLVH(SinV2andtheRinV5>35
mm)andfeaturesofRVH.
RVHisseenasrightaxisdeviation,tallbiphasicQRScomplexesinmultipleleadsanddeepSwavesinV56.
ManyVSDsareassociatedwithathrill(apalpablemurmur)atthelowerleftsternaledge.
Aorticstenosis(OptionA)isincorrect.AorticstenosisproducesLVH.
Hypertrophiccardiomyopathy(OptionB)isincorrect.HCMisnotthemostlikelydiagnosisbasedonthepresentationand
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findings.
Mitralregurgitation(OptionC)isincorrect.MRproducesLVH.
Tricuspidregurgitation(OptionD)isincorrect.TRproducesRVH.
41924
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Question101of295
A70yearoldmanisreferredbyhisGPforadviceregardingoptimisationofsecondaryprevention.Hehasahistoryof
angina,withexcellentcontrolofsymptomsonacombinationofaspirin,dipyridamoleMR,atenolol50mgod,simvastatin
40mgodandisosorbidemononitrate20mgbd.Hispulserateis70bpmandbloodpressureis144/86mmHg.Theonly
otherrelevantpasthistoryincludesanischaemicstroke2yearsagofromwhichhemadeacompleterecovery.
Whatadditionaltherapywouldyouconsideradding?
A Bendroflumethiazide
B Diltiazem
C Doxazosin
D Nicorandil
E Perindopril
Explanation
Treatingvasculardisease
Mostclinicianswouldnowrecommendtheadditionofangiotensinconvertingenzyme(ACE)inhibitorsfor
patientswithvasculardisease,irrespectiveofleftventricularfunction
Thisisbasedonevidencefromlargetrials,suchasPROGRESS(perindopril)andHOPE(ramipril)
BenefitsofACEinhibitionseemtonotbepurelyrelatedtoareductioninbloodpressurebeneficiallocalvascular
andmyocardialeffectsarealsoseen
Bloodpressureisnotyetoptimisedinthispatientandfurtherantihypertensivetherapyiswarranted
TheadditionofanACEinhibitorshouldbringthistothedesiredlevel(<140/85mmHg)
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Question102of295
A23yearoldwomanpresentstotheGPcomplainingofpalpitations.Shesaysthesearerapidandwhenshegetsthemshe
feelslightheadedandsick.Theytendtocomeonwithoutwarning,buthaveoccurredwhenshehasbeenoutdancingwith
friends,andafteragameofsquash,andononeoccasionatrest.OnexaminationshelookswellherBMIis21,pulse70
bpmregular,BP122/70mmHg.Bloodtestresultsareshowninthetablebelow:
Hb 13.1g/dl
WCC 5.4109/l
PLT 251109/l
Na+ 139mmol/l
K+ 4.0mmol/l
Creatinine 75mol/l
Whichoneofthefollowinginvestigationsismostlikelytohelpwiththediagnosis?
A Tilttabletest
B Continuouslooprecorder
C 24hHoltermonitor
D 3dayHoltermonitor
E 12leadECG
Explanation
Continuouslooprecorder
Althougha12leadECGmayrevealevidenceofstructuralheartdiseaseleadingtochangesintherestingECG,or
anaberrantpathwaysuchasthatfoundinWolfParkinsonWhitesyndrome,moreoftenthannotitwillbenormal
AHoltermonitormayalsobeinplaceduringaperiodwherenopalpitationsoccur
Bycontrast,acontinuouslooprecordercanbeactivatedbythepatientduringsymptomsandthereforecarriesthe
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greatestchanceofrecordingthearrhythmia
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Question103of295
A50yearoldmanpresentswitha1hourhistoryofseverecentralchestpain.Thereisnosignificantpastmedicalhistory.
Heishaemodynamicallystablewithapulserateof90bpmandbloodpressureof120/70mmHg.ECGshows5mmof
STsegmentelevationintheanteriorleads(V2V4).Hereceivedaspirin300mgintheambulanceanddiamorphine5mg.
Whatwouldbethedefinitivetherapy?
A Clopidogrel75mg
B Enoxaparin
C GIIb/IIablocker
D Percutaneouscoronaryintervention
E Tissueplasminogenactivator
Explanation
Anteriormyocardialinfarction
Thisrelativelyyoungmanhaspresentedearlywithacuteanteriormyocardialinfarction(MI)
Thekeytherapeuticaimisearlyreperfusioninanattempttosavethemyocardium
Treatment
Incentreswithrapidaccesstoprimaryangioplastythiswouldbetheoptimumstrategyandguidelinesnow
suggestthisshouldbethenormintheUK
Ifangioplastyisnotavailablethenthrombolysiswithtissueplasminogenactivatoristhenextbestalternative
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Question104of295
Theuseofprostaglandintokeeptheductusarteriosusopenisnecessaryinwhichofthefollowing?
A Tricuspidatresia
B Atrioventricularseptaldefect
C Totalanomalouspulmonaryvenousreturnwithobstruction
D Aorticstenosis
E Atrialseptaldefect
Explanation
TheanswerisTricuspidatresia
Keepingtheductusarteriosuspatentisbeneficialinanycyanoticheartdisease.Thatis,anyconditioninwhichblood
flowtothelungsforoxygenationiscompromised.
Thecyanoticheartdiseasesinclude:
tetralogyofFallot(ToF)
totalanomalouspulmonaryvenousconnection
hypoplasticleftheartsyndrome(HLHS)
transpositionofthegreatarteries(dTGA)
truncusarteriosus(persistent)
tricuspidatresia
interruptedaorticarch
pulmonaryatresia(PA)
pulmonarystenosis(critical)
Ineachoftheseconditions,prostaglandinEmaybeadministeredtokeeptheductusopen.
Intricuspidatresia,thetricuspidvalvehasfailedtodevelop,meaningthereisnoconnectionbetweentherightatrium
andventricle.Consequently,therightventricleishypoplasticorevenabsent.Thereforethereislittlebloodtravelling
tothelungs,leadingtoseverecyanosis.Forthechildtosurvive,theremustbeanASD(allowingbloodfromthe
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rightatriumintotheleft)andaVSD(toallowbloodfromtheLVintowhateverRVispresentandontothe
pulmonaryarteries).
Atrioventricularseptaldefect(OptionB)isincorrect.Atriovetnricularcanaldefectsarelefttorightshuntsthatis,there
isnocyanosisandnoneedtokeeptheductusarteriosusopen.
Totalanomalouspulmonaryvenousreturnwithobstruction(OptionC)isincorrect.Totalanomalouspulmonaryvenous
connection(TAPVC),alsoknownastotalanomalouspulmonaryvenousdrainageandtotalanomalouspulmonaryvenous
return,iswhereallthepulmonaryveinsconnectintothevenouscirculationtypicallytheSVC,butalsothe
brachiocephalicveinsorportalveins.Thereforeallthebloodismixedfortheretobesurvival,theremustbeanASDor
patentforamenovale.Inthiscondition,prostaglandinEwillhelpmaintaintheductusarteriosusandthereforeallow
oxygenatedbloodfromtherightsidedcirculationtoentertheaorta.However,thisisnottherightanswerhere,sincewe
areaskedaboutTAPVCwithobstructionthisisthemostseverevariantofthiscondition,inwhichthepulmonaryveins
enterthesystemicveinsatanacuteanglewhichpreventseasyflowofblood.Thisleadstopulmonaryvenouscongestion
andhypertension.Inthissubtype,givingPGE1candilatethepulmonaryarteriesandincreasepulmonaryflowordilate
theductusarteriosusandsystemicarteriesandincreaserighttoleftshuntingandworsencyanosis.Therefore,itisnot
recommended.Thechildiscriticallyunwellandneedsemergencysurgeryimmediatelyifitistosurvive.
Aorticstenosis(OptionD)isincorrect.Aorticstenosisdoesnotrequireprostaglandins.
Atrialseptaldefect(OptionE)isincorrect.ASDsdonotrequireprostaglandins.
41901
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Question105of295
A75yearoldmanwithisolatedsystolichypertension,whoalsohasurinaryincontinence,goutandasthma,attends
outpatientswithabloodpressurereadingof190/86mmHg.
Whichoneofthefollowingdrugswouldbemostappropriateforthispatient?
A Amlodipine
B Atenolol
C Bendrofluazide
D Doxazosin
E Valsartan
Explanation
TheanswerisAmlodipine
ThemanagementofhypertensionisrecommendedtouseA+CandthenD(ACEinhibitor+calciumchannel
antagonistandthenadiuretic).Inpatientsunder55,thefirstdrugshouldbeanACEinhibitor.Patientsover55years
old,andallofAfricanorCaribbeandescent,shouldbestartedwithacalciumchannelantagonist.
Amlodipine,adihydropyridinecalciumchannelblocker,isthedrugofchoiceforthetreatmentofisolatedsystolic
hypertensionintheelderlythereforeAiscorrect.
Atenolol(OptionB)isincorrect.Asthmarulesouttheuseofblockersadditionally,blockershavebeenremovedfrom
theguidanceforhypertensivesastheyhaveminimalgain.
Bendrofluazide(OptionC)isincorrect.Thiazidesareeffectivebutwilllikelyonlyworsenhisincontinenceandmakehis
goutworsethereforethiswouldbesecondline.
Doxazosin(OptionD)isincorrect.Althoughdoxazosinmaybehelpfulforbenignprostatichyperplasiasymptomsitisnot
afirstchoiceantihypertensiveingeneralblockersarereservedforuseinresistanthypertension.
Valsartan(OptionE)isincorrect.Thiswouldnotbethemostappropriatechoiceforthispatient.
41966
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Question106of295
Apatienthastuboeruptivexanthomas,distributedsubcutaneouslyandmainlyontheextensorsurfaceofextremities.
Whatistheprobablediagnosis?
A TypeIhyperlipoproteinaemia
B TypeIIhyperlipoproteinaemia
C TypeIIIhyperlipoproteinaemia
D TypeIVhyperlipoproteinaemia
E TypeVhyperlipoproteinaemia
Explanation
Xanthomas
TuboeruptivexanthomasoccurintypeIIIhyperlipoproteinaemia
Eruptivexanthomasareassociatedwithhyperchylomicronaemia(typeIandtypeVhyperlipoproteinaemia)
Xanthomatendinosum,whicharenodularswellingsoftendons,usuallyoccurintypeIIhyperlipoproteinaemia
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Question107of295
A64yearoldwomansuffersfromfrequentandpainfulurinarytractinfections.Afterherthirdcourseofantibioticsinthe
past6monthssheisadvisedbytheGPtotakecranberryjuicesupplements.Significantpastmedicalhistoryofnote
includeshypertension,forwhichshetakesramiprilandbendroflumethiazide,andhypercholesterolaemia,forwhichshe
takessimvastatin.Thereisalsoahistoryofparoxysmalatrialfibrillation,forwhichshetakeswarfarinandamiodarone.
Whichoneofhermedicationsismostlikelytointeractwiththecranberryjuice?
A Simvastatin
B Amiodarone
C Bendroflumethiazide
D Warfarin
E Ramipril
Explanation
Warfarinandcranberryjuice
Cranberryjuicecontainsanumberofbioflavinoids,someofwhicharethoughttocauseinhibitionofthe
cytochromep4502C9isoenzyme,whichisresponsibleforwarfarinmetabolism
ThewarfarininteractionwasgivenasaCommitteeforSafetyofMedicines(CSM)warningin2003andfeatures
prominentlyintheMRCPexamination
Othernotes
Metabolismofsimvastatinisinhibitedbygrapefruitjuice
14949
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Question108of295
A70yearoldobesemanisadmittedwitha6hourhistoryofchestpain.AnECGrevealsaninferiorwallmyocardial
infarction.Measurementofwhichoneofthefollowingwouldbemostsensitiveandspecificinconfirmingmyocardial
damage?
A Creatinekinase
B CreatinekinaseMB
C CardiacspecifictroponinT
D Aspartateaminotransferase
E Lactatedehydrogenase
Explanation
Diagnosingmyocardialinfarction
TroponinTandtroponinIareregulatoryproteinswithaveryhighspecificityforcardiacinjury
Theyarereleasedearly(24h)andcanpersistforupto7days
Mosthospitalschecklevelsat6and12hoursafteradmission
TheyaremoresensitiveandcardiospecificthancreatininekinaseMB,acardiacspecificisoformofcreatine
kinaseallowinggreaterdiagnosticaccuracythancreatinekinase
Bothaspartateaminotransferaseandlactatedehydrogenase(LDH)arenonspecificenzymesthatarerarelyused
nowadaysforthediagnosisofmyocardialinfarction
LDHpeaksat34daysandremainselevatedforupto10daysfollowingacardiacevent,andcanthusbeusefulin
confirmingmyocardialinfarctioninpatientspresentingseveraldaysafteranepisodeofchestpain
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Question109of295
A45yearoldmanattendsforreview.Hehasbeensufferingincreasingshortnessofbreathoverthepastfewyears.Heis
anonsmokerwhodrinks20unitsperweekofalcoholandhasnosignificantpastcardiovascularhistory.Nowhepresents
withwhatseemstohavebeenatransientischaemicattack(TIA),withweaknessandcoordinationproblemsaffectinghis
leftside,whichhaveresolvedoverthepast24hours.Onexaminationbloodpressureis142/95mmHgandheisinsinus
rhythm.Thereisnoopeningsnap,butthereisadiastolicmurmur,whichchangesincharacteraccordingtoposture.
Bloodsareunremarkable,includingCreactiveprotein(CRP),whichisinthenormalrange.
Whichoneofthefollowingdiagnosesfitsbestwiththisclinicalpicture?
A Aorticstenosis
B Leftatrialmyxoma
C Mitralregurgitation
D Mitralstenosis
E Rightatrialmyxoma
Explanation
TheanswerisLeftatrialmyxoma
Leftatrialmyxoma
Thispatienthassufferedatransientischaemicattack(TIA),mostlikelyowingtoembolusfromanintracardiac
cause.
Onepossibleclinicalexplanationcouldbemitralstenosis,leftatrialenlargementandatrialfibrillation,
leadingtoclotformationwithintheatrium(asimpliedbyoptionD),butthispatientisinsinusrhythm,there
isnoopeningsnaponauscultation,andthemurmurchangesincharacterwithposture.Thiswouldbest
describeanatrialmyxoma.Asthesearemostcommonintheleftatrium,leftatrialmyxomaisthebest
answer.Furthermore,thepatientpresentswithsystemicemboliratherthanpulmonarycirculationemboli
thereforeonlyaleftsidedheartproblemcanexplainthepresention.
Atrialmyxomasaregelatinous,friabletumourstheyleadtotransientsignsofmitralstenosisthatoccuronly
ifthetumourapproachesthemitralvalveorificetheytendtobeattachedtotheatrialwallinamannerthat
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allowsthemtobemobilethetumourwillflopinandoutofthemitralorifice,leadingtoamurmurthat
changesaccordingtopatientposition(diastolicplop).Calcificationofthetumourmaybevisibleonchest
XraybutdiagnosisisbestmadeoncardiacMRI,whichcandeterminetissuecharacteristics.
Sincetheyarefriable,smallfragmentscanbreakoffduringmovementandcauseTIAorstrokeevents.
Rightatrialmyxomasaremorerareanddifficulttoidentifyclinicallytheremaybeevidenceofmultiple
pulmonaryinfarctsduetoformationofemboli.
Definitivetreatmentinvolvessurgicalexcisionrecurrencerateisextremelylow,butfollowupis
recommendedforaperiodof5years.
Genuinemetastasisofmyoxomasisrare
Aorticstenosis(OptionA)isincorrect.AorticstenosisisnotassociatedwithTIAs.
Mitralregurgitation(OptionC)isincorrect.MitralregurgitationisnotassociatedwithTIAs.AlthoughAFcanoccurin
patientswithMRemboliceventsmaybelesscommonasthehighvelocityjetsofregurgitationmaypreventclot
formationintheleftatrium.
Mitralstenosis(OptionD)isincorrect.Onepossibleclinicalexplanationcouldbemitralstenosis,leftatrialenlargement
andatrialfibrillation,leadingtoclotformationwithintheatrium(asimpliedbythisoption),butthispatientisinsinus
rhythm,thereisnoopeningsnaponauscultation,andthemurmurchangesincharacterwithposture.
Rightatrialmyxoma(OptionE)isincorrect.Leftatrialmyxomaismorecommon,andthepresentationmayonlybe
explainedbyaleftsidedheartproblemasdescribed.
42024
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Question110of295
A54yearoldmanismovedtothecatheterlabforurgentPTCAafterinferoposteriormyocardialinfarction.Thenurses
askyoutoseehimashehashypotension,(BP90/50mmHg).HisJVPismarkedlyelevated,pulseis65/minandregular.
Thechestisclearwithnosignsofheartfailure,andtherearenomurmurs.ECGconfirmsinferoposteriorchanges
consistentwithanacuteSTEMI.
Whichofthefollowingisthemostlikelydiagnosis?
A Aorticdissection
B Leftventriculardysfunction
C Rightventriculardysfunction
D Ventricularfreewallrupture
E Mitralregurgitation
Explanation
TheanswerisRightventriculardysfunction
Approximately10%ofpatientswithanacuteinferoposteriorinfarctpresentwithsignificantrightventriculardysfunction.
InthiscaseRVoutputisreducedleadingtosystemichypotensionandamarkedlyelevatedJVP.Giventheinfarctisinthe
inferiorterritory,itseemsheisalsounabletomountatachycardiatomaintainhisBP.Managementinvolvesmaintaining
adequateRVfillingpressures,(withCVPmonitoringtoreducetheriskofoverload),andtheuseofinotropessuchas
Dobutamineifrequired.
LVdysfunction,ventricularfreewallruptureandmitralregurgitationareassociatedwithacuteleftventricularfailure.
AorticdissectionintheabsenceofworseningpainspreadingtothebackoranextensionofECGchangesisunlikely.
36432
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Question111of295
A54yearoldmansuddenlydevelopsweaknessoftheleftsideofhisfaceandarmanddifficultyinspeech.Thisepisode
lastsfor15minutes.Hehasahistoryofhypertension,whichiswellcontrolledonacalciumchannelblockingagent.His
brotherhadhadasevere,disablingstrokeattheageof50.
Hischolesterollevelis5.8mmol/litre.ACTscanperformedthesamedayshowedthepresenceoftwooldlacunarstrokes
intherightmiddlecerebralarteryterritory.CTangiogramofthecarotidsystemshowsa60%stenosisoftherightinternal
carotidartery.
Whichoneofthefollowingfactorsisthestrongestpredictorofhisbeingatahighriskofearlyrecurrentstroke?
A Positivefamilyhistory
B Historyofhypertension
C Hyperlipidaemia
D Presenceofmoderatecarotidstenosis
E PresenceofpreviousstrokesonCTscan
Explanation
TheanswerisPresenceofmoderatecarotidstenosis
Thisisthestrongestpredictorofriskfromtheoptionsoffered.
Thisisatransientischaemicattack(TIA)sincetheepisodelastedlessthan24hours
About1520%ofpatientswithstrokehaveaprecedingTIA
Theissueofsubsequentstrokepreventionisthereforeparamountwhenmanagingsuchawarningevent
Theurgencyoftreatmentofminorstrokeortransientischaemicattackshoulddependontheearlyriskof
majorstroke
TheriskofrecurrentstrokeduringthefirstfewdaysafteraTIAorminorstrokeismuchhigherthan
previouslyestimated
Recentstudieshaveidentifiedpotentialriskfactorsforthoseathighestriskofsubsequentstroke:
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Age>60years
Hypertension
Durationofsymptoms>60min
Certainclinicalfeatures(unilateralweakness,speechimpairment)
Presenceofdiabetesmellitus
ThepresenceofinfarctiononCTbrainscansinpatientswithTIAorminorstrokeisassociatedwith
anincreasedriskofstrokerecurrence
ThereareseveraltreatmentsthatarelikelytobeeffectiveinpreventingstrokeintheacutephaseafteraTIAor
minorischaemicstroke,includingaspirin,possiblyincombinationwithclopidogrelandanticoagulationinpatients
withatrialfibrillation,andpossiblystatins.
Thesubgroupofpatientswithlargearteryatherosclerosis(usuallycarotidbifurcationstenosis)accountsfor
thelargestproportionofearlyrecurrentstrokes
ArecentpopulationbasedstudyofprognosisofpatientswithTIAand50%symptomaticcarotid
arterystenosisreportedrisksofstrokeofabout20%duringthe2weeksbeforeendarterectomy
Otherstudieshavehighlightedthehighriskofstrokeifendarterectomyisdelayed,andhencethe
rapiddecreaseinbenefitfromsurgerywithincreasingtimesinceevent
ForneurologicallystablepatientswithTIAandminorstroke,benefitfromendarterectomyisgreatest
ifdonewithin2weeksoftheevent
Theriskbenefitratiooftreatingsymptomaticcarotidstenosis(secondarystrokeprevention)differs
fromthatoftreatingasymptomaticstenosisaspartofprimaryprevention,wherestenosismustbe
severeinordertojustifytheriskofsurgery
TheEuropeanSocietyofCardiologyGuidelinesformanagingcarotidstenosesafterstrokeareshownhere.
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http://eurheartj.oxfordjournals.org/content/ehj/32/22/2851.full.pdf
(http://eurheartj.oxfordjournals.org/content/ehj/32/22/2851.full.pdf)
(Reference:TenderaM,etalESCGuidelinesonthediagnosisandtreatmentofperipheralarterydiseases:Document
coveringatheroscleroticdiseaseofextracranialcarotidandvertebral,mesenteric,renal,upperandlowerextremity
arteries*TheTaskForceontheDiagnosisandTreatmentofPeripheralArteryDiseasesoftheEuropeanSocietyof
Cardiology(ESC).EuropeanHeartJournal.201132:28512906
Positivefamilyhistory(OptionA)isincorrect.Thisisnotthestrongestpredictorofriskfromtheoptionsoffered.
Historyofhypertension(OptionB)isincorrect.Thisisnotthestrongestpredictorofriskfromtheoptionsoffered.
Hyperlipidaemia(OptionC)isincorrect.Thisisnotthestrongestpredictorofriskfromtheoptionsoffered.
PresenceofpreviousstrokesonCTscan(OptionE)isincorrect.Thisisnotthestrongestpredictorofriskfromtheoptions
offered.
41902
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Question112of295
A50yearoldwomanisreferredtooutpatientsforapreviouslyasymptomaticatrialseptaldefect(ASD).Sheisnewto
theareaandwaslastseenaround10yearsagoinherpreviouslocalhospital.Sheisasmokerbutwithoutothersignificant
medicalhistory.Shenowcomplainsofshortnessofbreathonexertion,togetherwithperipheraloedema.Clinical
examinationrevealshertobeclubbedandcyanosed.Herpulserateis90bpmandbloodpressure98/60mmHg.Echo
demonstratesadilatedrightheartwithanestimatedrightventricularpressureof90mmHgandsignificanttricuspidand
pulmonaryregurgitation.
Whatisthelikelydiagnosis?
A Corpulmonale
B Eisenmengersyndrome
C Infectiveendocarditis
D Primarypulmonaryhypertension
E Pulmonaryembolidisease
Explanation
TheanswerisEisenmengersyndrome
Thiswomanhasdevelopedmassiveirreversiblepulmonaryhypertensionasaconsequenceofapreviouslefttoright
shunt.
Pulmonarypressureshavenowreachedsystemiclevelbasedupontheechocardiographicfindings.
Longstandinglefttorightshuntswillcausethepulmonarycirculationtobeexposedtoelevatedpressuresthis
leadstoanarterialmedialhypertrophyandanelevationofpulmonaryarterypressures(iepulmonaryhypertension).
Whenthesepressuresexceedsystemicpressures,thereisreversalofthelefttorightshunt.Thiscanoccurwithany
conditionthatallowslefttorightshunts,suchaspreviouslyundiagnosedASD,ventricularseptaldefect(VSD)or
patentductusarteriosus.ItmayalsoresultfromanincompletelycorrectedFallotstetralogyorEbsteinsanomaly.
Oncereversaloftheshunthasoccurred,itisreferredtoasEisenmengersyndrome.Prognosisispoor,althoughafew
patientsmaybecandidatesforheartlungtransplantation.
Symptomatictreatmentisdirectedtowardsrightheartfailurewithpredominantlydiureticusage.
ComplicationsofEisenmengerssyndrome:
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Complicationsincludepolycythaemia,bleedingdisordersandcerebralembolismorabscess.
Sincethereisaparticularlyhighriskinthoseofchildbearingage,patientsshouldbegivenappropriateadviceand
informationtoavoidpregnancy.
SyncopalepisodesinpatientswithEisenmengercanbeaforewarningofdeath.
Corpulmonale(OptionA)isincorrect.Thereisnothingtosuggestpreviousairwaysdiseasetocausecorpulmonale.
Infectiveendocarditis(OptionC)isincorrect.Therearenoinfectivesymptomstosuggestinfectiveendocarditis.
Primarypulmonaryhypertension(OptionD)isincorrect.Primarypulmonaryhypertensionisunlikelysincethereisa
clearcauseofsecondarypulmonaryhypertension(anuntreatedASD).
Pulmonaryembolidisease(OptionE)isincorrect.Pulmonaryembolicancausepulmonaryhypertensionthatischronic
andrecurrent,butislesslikelytobetheanswerinthisscenariobecauseoftheknownASD.
41942
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Question113of295
A30yearoldmanpresentswith1hourofcentralcrushingchestpain.Headmitstoregularcocaineuse,includingonthe
eveningthathepresentstotheEmergencyDepartment.Otherhistoryofnoteincludessmoking10cigarettesperdayanda
familyhistoryofmixedhyperlipidaemia.OnexaminationhisBPis220/120mmHg,butthisfallsto180/80mmHgafter
diamorphine.Hehasasinustachycardiaof110bpm.Hehasbeengiven300mgofaspirinbytheambulancecrew.The
tablebelowshowstheinvestigationresults.
Hb 13.8g/dl
WCC 5.9109/litre
PLT 211109/litre
Na+ 141mmol/litre
K+ 4.9mmol/litre
Creatinine 110mol/litre
ECG AnteriorSTelevationconsistentwithacutemyocardialinfarction
Whichoneofthefollowingisthemostappropriatewaytomanagehim?
A Abciximab
B Percutaneouscoronaryintervention
C Lowmolecularweightheparin
D Streptokinase
E rtPA
Explanation
Cocaineassociatedchestpain
GuidelinessuggestthatpatientswithevidenceofacuteSTEMIshouldbemanagedinthesamewayasthose
withouthistoryofcocaineabuseassuch,percutaneoustransluminalcoronaryangioplasty(PTCA)isthemost
appropriateoption
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Somenotableexceptionsdoexisthowever,mainlyarounduseofblockade,whichisnotrecommendedin
patientswithahistoryofcocaineabuse,asitmayworsencoronaryarteryvasospasm
Instead,nitratesorcalciumchannelblockadearerecommendedasalternatives
WithrespecttouseoflowmolecularweightheparinorIIbIIIaantagonists,theAmericanHeartAssociation
guidelinesendorsetheiruseinaclinicallyappropriatesituationdespitethefactthatnorandomisedcontrolledtrial
evidenceexists(http://circ.ahajournals.org/content/117/14/1897.full
(http://circ.ahajournals.org/content/117/14/1897.full))
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Question114of295
A28yearoldwomanwhoisknowntohaveacardiacmurmurbecomespregnant.Itisnotedthattheintensityofher
murmurdiminishesduringherpregnancy.
Whichcardiacabnormalityisshelikelytohave?
A Aorticstenosis
B Aorticregurgitation
C Tricuspidstenosis
D Pulmonarystenosis
E Atrialseptaldefect(ASD)
Explanation
TheanswerisAorticregurgitation
Thefallindiastolicbloodpressureduringpregnancyleadstoareductioninthemurmurofaorticregurgitation.
Murmursfollowpressuregradientsifthebloodpressureislower,thenthedifferencebetweentheaorticpressure
andLVpressureisless,makingthemurmurquieter.
Haemodynamicchangesinpregnancy
Duringpregnancy,cardiacoutputandbloodvolumeincreasefromthesecondmonthuptothe30thweekto30
50%abovethenormallevels
Theaverageincreaseinbloodvolumeduringpregnancyamountsto1600ml,andthereisalsoanincreased
metabolicworkload
Theincreaseincardiacoutputismediatedviaincreaseinbothstrokevolumeandtoalesserextentheartrate,along
withadramaticfallintotalperipheralvascularresistance
Examinationfindings
Warmextremities
Atachycardiawithalargevolumepulse
Aslightriseinvenouspressure
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Lowereddiastolicbloodpressureduetovasodilatation:thisisresponsibleforthefadingoftheaorticregurgitation
murmur
Theapexbeatisdisplaced,becauseofcardiomegalyandaraiseddiaphragm
Theincreasedbloodflowmayproduceapulmonarysystolicmurmurandathirdheartsound
FixedsplittingofS2inASD
S2ismadeupoftheclosureA2andP2.Innormalconditions,A2andP2closenearsimultaneously
Innormalconditions,splittingofS2willoccurduringinspirationbecausetheincreaseinvenousreturnoverloads
therightventricleanddelaystheclosureofthepulmonaryvalve(A2closesfirst,thenP2)
InASD,thereisshuntingofbloodfromtheleftatriumintotherightatriumandthereforetherightventriclecanbe
thoughtofascontinuouslyoverloaded,producingawidelysplitS2.Inspirationdoesnotalterthesplitting,because
theatriaarelinkedbytheASD,meaningthatinspirationproducesnonetpressurechangebetweenthem.Therefore
thereisnosignificantchangeinthesplittingduringinspirationorexpirationandthereforeitisfixedsplitting
Aorticstenosis(OptionA)isincorrect.Theincreaseinbloodvolumeandincreasedcardiacoutputleadtoallstenosic
murmursbecomingmoreprominent(thereisincreasedflowacrossthevalve,withmoreturbulenceandpressuregradient,
leadingtoaloudersound).
Tricuspidstenosis(OptionC)isincorrect.Theincreaseinbloodvolumeandincreasedcardiacoutputleadtoallstenosic
murmursbecomingmoreprominent.
Pulmonarystenosis(OptionD)isincorrect.Theincreaseinbloodvolumeandincreasedcardiacoutputleadtoallstenosic
murmursbecomingmoreprominent.
Atrialseptaldefect(ASD)(OptionE)isincorrect.TypicallyanASDisassociatedwithfixedsplittingofthesecondheart
soundifamurmurispresentithasarisenfromincreasedpulmonaryvalvularflow,andhenceisincreasedduring
pregnancy.
41873
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Question115of295
A31yearoldwomanpresentstotheCardiologyClinicwithsuspectedprimarypulmonaryhypertension.Shehassuffered
increasingshortnessofbreathonminimalexerciseandreportsthreesyncopalepisodesoverthepast2months.Shehasno
pastmedicalhistoryofnoteandonlymedicationistheoralcontraceptivepill.AccordingtoherGPshehassignsofright
ventricularfailure.
Yoususpectprimarypulmonaryhypertension(PPH)
Whichofthefollowingisthemostlikelyfinding?
A QuietS1
B LoudS1
C QuietS2
D LoudS2
E Leftventricularheave
Explanation
TheanswerisLoudS2
PulmonaryhypertensionisassociatedwithaloudpulmonarycomponentofS2.Theaorticcomponentofthesecondheart
soundisenhancedinsystemichypertension.QuietS2isseeninaorticorpulmonarystenosis.CausesofaquietS1include
severecardiacfailure,mitralregurgitation,andrheumaticheartdisease.AccentuationofS1isseeninatrialfibrillation
andinmitralstenosis.Rightventricular,ratherthanleftventricularheaveisofcourseseeninpulmonaryhypertension.
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Question116of295
A75yearoldmanwithstablecongestivecardiacfailurepresentswithatrialfibrillation.Heishaemodynamicallystable
withaventricularrateof72.HehasagoodfunctionalstatechestXrayshowsclearlungfields.Echocardiography
revealedadilatedleftatriumandmildmitralregurgitation.
Whichdrugoptionwouldbemostbeneficialforthispatient?
A Aspirin
B Digoxin
C Frusemide
D Lidocaine
E Warfarin
Explanation
TheanswerisWarfarin
Atrialfibrillationpossessesariskofstroke,whichaccumulateseveryyearfromdiagnosis.Differentriskcalculators
areavailablehowever,fornonvalvularAF,theCHA2DS2VAScscoreshouldbeused.Inthiscase,thepatienthas
onlymildmitralregurgitation(MR)andnotsignificantmitralstenosisthereforetheatrialfibrillationisa
consequenceofhisageandcongestiveheartfailureanditisappropriatetousetheCHA2DS2VAScscore.Notethat
itistypicaltoobservemildMRinpatientswithcongestiveheartfailureduetodilatationofthemitralannulus.
Hescored3,basedonhisageandcongestiveheartfailure,andthereforeheshouldbeanticoagulatedwithwarfarin.
Therefore,thecorrectansweriswarfarinandnotaspirin.Ifthereiscontraindicationtowarfarin,thepatientcannot
tolerateitortheyexpressastrongpreference,thenaNOAC(nonvitaminKantagonistoralanticoagulant),suchas
apixaban,rivaroxabanordabigatran,canbeconsidered.Theseneweragentsdonotrequireregularmonitoring,
whichmakesadministrationeasier.Instudiestheyappeartobeasefficaciousaswarfarinwithbeneficialbleeding
profilesthedifficultyisthatthereisnowayofmonitoringcompliancebecausethereisnoreadilyavailableblood
test.
Aspirin(OptionA)isincorrect.Asdescribedhisscoreof2indicatesanticoagulationwithwarfarin.
Digoxin(OptionB)isincorrect.Inthiscase,hisventricularrateappearswellcontrolled(72bpm)sodigoxindoesnot
appeartoberequired.Ingeneral,digoxinonlycontrolsheartratesduringrest,withlittlecontrolwhenpatientsareactive
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andmobile.
Frusemide(OptionC)isincorrect.Furosemideisnotrequiredatpresentsincehisheartfailureiswellcontrolledandhis
chestisclear.
Lidocaine(OptionD)isincorrect.Lidocaineisusedtocontrolventriculararrhythmiasunresponsivetoamiodarone,and
thereforeisnottherightanswer.
41899
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Question117of295
A50yearoldwoman,whoisalreadyonramipril,frusemideandbisoprololforheartfailure,decompensatesandpresents
totheEmergencyDepartmentwithpulmonaryoedema.Herheartrateis120bpmandherbloodpressureis84/62mmHg.
Sheisgivenoxygenanddiamorphine.Thereismarkedperipheralpittingoedema.
Whichoneofthefollowingactionsisindicatedinherfurthermanagement?
A Increasediureticsandmaintainthecurrentdoseofblocker
B Increasediuretics,reducetheblockerdose
C Increasediuretics,increasetheblockerdose
D Increasediuretics,stopblockerspermanently
E Increasediuretics,stopblockersandrestartblockerswhenherlungsaredry
Explanation
TheanswerisIncreasediuretics,stopblockersandrestartblockerswhenherlungsaredry
Thispatienthaspresentedwithpulmonaryodemaandhypotensiononabackgroundofheartfailure.Followingthe
latestESCguidelinessheshouldbegivenIVloopdiuretics,oxygenifhypoxic,andIVopiate.AsthesystolicBPis
below85mmHg,herblockersshouldbeheldandanonvasodilatinginotrope(suchasdobutaminestartingat2.5
g/kgpermin)considered.Theblockersshouldberestartedwhensheisstabilisedandherpulmonaryoedema
resolved.
Theotheranswersarethereforeincorrect.
Inpatientswithoutalowbloodpressure,theblockerscouldbecontinuedatthecurrentdose.
Increasediureticsandmaintainthecurrentdoseofblocker(OptionA)isincorrect.Thiswouldnotbethebestchoicefor
thereasonsdescribed.
Increasediuretics,reducetheblockerdose(OptionB)isincorrect.Thiswouldnotbethebestchoiceforthereasons
described.
Increasediuretics,increasetheblockerdose(OptionC)isincorrect.Thiswouldnotbethebestchoiceforthereasons
described.
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Increasediuretics,stopblockerspermanently(OptionD)isincorrect.Thiswouldnotbethebestchoiceforthereasons
described.
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Question118of295
A74yearoldmanpresentswithacuteonsetpalpitations,ECGshowedregulartachycardiawithaventricularrateof150.
Hehasahistoryofhypertensiontreatedwithramiprilandamlodipine,buthasnoothersignificantpastmedicalhistory.
Hesmokes5cigarsperday.OnexaminationhisBPis110/70mmHghispulseisveryrapid,atleast130bpm.Thetable
belowcontainsinvestigationresults.
Hb 12.9g/dl
WCC 6.7109/litre
PLT 291109/litre
Na+ 141mmol/litre
K+ 5.3mmol/litre
Creatinine 141mol/litre
regularnarrowcomplextachycardiawithventricularrateof150bpmsawtoothpatternparticularly
ECG
evidentinleadsII,IIIandaVF
Whichoneofthefollowingrhythmsisitmostlikelytobe?
A IdioventriculartachycardiawithdissociatedAVresponse
B Atrialflutter
C Atrialfibrillation
D AVnodalreentranttachycardia
E Atrioventricularreentranttachycardia
Explanation
Atrialflutter
ThesawtoothpatternwhichisparticularlywellcharacterisedinleadsII,IIIandaVFistypicalofatrialflutter
with2:1block
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Itisthesecondmostcommontachyarrhythmiaafteratrialfibrillation,prevalenceinthe6590yearagegroup
beingaround0.51%
Treatment
Electricalcardioversionmaybeattemptedotherwiseamiodaroneisthedrugofchoiceforchemicalcardioversion
Inpatientsinwhomcardioversionisunsuccessful,ventricularratemaybecontrolledwithnondihydropyridine
calciumchannelblockerssuchasverapamilordiltiazem,orcardioselectiveblockerssuchasmetoprolol
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Question119of295
A72yearoldmanisbeingreviewedintheCardiacUnit.Hehasdevelopedaventriculartachycardiaof160bpm,looks
unwellandhasabloodpressureof70/52mmHg.
Whichoneofthefollowingwouldbethemostimmediatetreatmentofchoice?
A Immediateheparinisation
B Intravenouslidocaine
C DCcardioversion
D Intravenousadenosine
E Carotidsinusmassage
Explanation
TheanswerisDCcardioversion
Thepresenceofabroadcomplextachycardiawithalowbloodpressureisaclearindicationtoperformimmediate
DCcardioversion.
Immediateheparinisation(OptionA)isincorrect.Thisisnottheimmediatetreatmentforventriculararrhythmia.
Intravenouslidocaine(OptionB)isincorrect.IntravenouslidocaineisanalternativeiftheVTwashaemodynamically
stableitistypicallyusedsecondlineaftertryingamiodaroneinfusionsinceneitheristrueinthescenario,thiscannotbe
thecorrectanswerchoice.
Intravenousadenosine(OptionD)isincorrect.IVadenosineisusedinthediagnosisandterminationofSVTandsoisnot
anappropriatechoicehere.
Carotidsinusmassage(OptionE)isincorrect.CarotidsinusmassageisusedinthediagnosisandterminationofSVTand
soisnotanappropriatechoicehere.
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Question120of295
A60yearoldwomanpresentswithexertionaldyspnoeaonrushingupstairsorgoingtothelocalshops.Sheisinsinus
rhythmat80bpmandherbloodpressureis160/80mmHg,withoutevidenceoffluidoverload.Sheisalreadytakingthe
maximumdoseofanangiotensinconvertingenzymeinhibitorandfrusemide40mgoncedailyforlongstanding
hypertension.Echoconfirmssignificantlyimpairedleftventricularsystolicfunction(ejectionfraction35%).Hercoronary
arteriesandrenalfunctionarenormal.Whatadditionalmedicationshouldbeconsideredforsymptomaticandprognostic
benefit?
A Amiodarone
B Amlodipine
C Bisoprolol
D Isosorbidemononitrate
E Losartan
Explanation
Treatingchronicheartfailure
Thiswomanhaschronicheartfailure(CHF)withcompatiblesymptomsandobjectiveevidenceofleftventricular
dysfunctionatrest
Thereisoverwhelmingevidenceforthelongtermprognosticandsymptomaticbenefitofanangiotensin
convertingenzyme(ACE)inhibitorinpatientswithCHF
RecenttrialssupporttheprognosticandsymptomaticbenefitofcertainblockersinCHFpatientsinadditionto
ACEinhibitors
IntheUK,bisoprololandcarvedilolarethetwolicensedagentsforuseinthiscondition
trialsofbothbisoprololandcarvedilolsuggestareductionofaround30%inmortality,particularlyin
patientswithseverecardiacfailure
IsosorbidemononitrateandamlodipinearesafetouseinpatientswithCHFeitherforsymptomatictreatmentof
anginaorassociatedhypertension
thereisnoevidencethattheyinfluenceoutcome
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Question121of295
A70yearoldmanundergoessuccessfulDCcardioversion(DCCV)foratrialfibrillation(AF).
Whichoneofthefollowingfactorsbestpredictslongtermmaintenanceofsinusrhythmfollowingthisprocedure?
A AFdurationlessthan6monthspriortocardioversion
B Ageover75years
C Noalcoholintake
D Normalleftventricularfunction
E Warfarintherapy
Explanation
TheanswerisAFdurationlessthan6monthspriortocardioversionAFwithashorterdurationhasthegreatest
chanceofsuccessfulcardioversion,andmaintenceofsinusrhythm.After6months,successratesbegintofalland
after12months,DCCVbecomesunlikelytorestoresinusrhythmforlongperiods.ThepresenceofAFappearsto
triggeratrialremodelling,whichcreatesanatomicalandelectricalconditionsthatfavourfurtherAF(leadingtothe
expressionAFbegetsAF).
Ageover75years(OptionB)isincorrect.AgeismuchlessimportantthanthedurationofAF
Noalcoholintake(OptionC)isincorrect.AlcoholisanimportantaetiologicalfactorbutislesssignificantthanAF
durationanecdotally,somepatientsaremorepronethanotherstoreturntoAFafteranalcoholicdrink.
Normalleftventricularfunction(OptionD)isincorrect.Cardioversionhasamuchhighersuccessrateinpatientswith
structurallynormalhearts,buttheleftatrialsizeisabetterpredictorthanleftventricularfunction(hencethisoptionis
false).SpecificallyAFismorelikelytopersistifLAdiameteris>5cm.Patientswithabnormaldilatedventriclesarealso
lesslikelytoremaininsinusrhythm.
Warfarintherapy(OptionE)isincorrect.Warfarinisimportanttoreducestrokeriskandallpatientsscheduledtohave
DCCVmusthaveatherapeuticINR(>2)for46weekspriortoDCCV.However,warfarinpersedoesnothelptorestore
ormaintainsinusrhythm.
42000
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Question122of295
A38yearoldmanofChinesedescentwhosmokes60cigarettesperdaypresentstohisGP.Heisdevelopingpainatrest
inhislegs,andisunabletowalkmorethanafewyardsowingtoischaemicpain.Onexaminationthereisprolonged
capillaryrefillandnecroticulcersatthetipsofhistoes.Thereisalsoevidenceofthrombophlebitis.
Whatdiagnosisfitsbestwiththisclinicalpicture?
A Buergersdisease
B Familialhypercholesterolaemia
C Polyarteritisnodosa
D Simpleperipheralvasculardisease
E Temporalarteritis
Explanation
TheanswerisBuergersdisease
Inthisscenario,itisclearthereisvascularcompromiseoftheleg.TheconditionstoconsidermostareBuergers
disease,Simpleperipheralvasculardisease,andFamilialhypercholesterolaemia.
Buergersdisease
Buergersdisease(thromboangiitisobliterans)isanocclusiveinflammatorydiseaseofsmalltomedium
sizedarteriesoftheupperandlowerextremities.
Patientshaveclaudicationwithdiminishedorabsentpulses.Thefeetorlegsmaybecyanosedorduskythe
skinisthinandwithouthair.Ulcerationsoccurandnecrosisfollows.Patientscanhaveacutelyinflamedand
thrombosedarteriesandveins.
Histopathologyexaminationofaffectedarteriesrevealsfreshinflammatorythrombuswithinbothsmalland
mediumsizedarteriesandveins,withgiantcellssurroundingthethrombus.
Thediseaseisverycloselyassociatedwithheavysmokingcontinuedsmokingafterdiagnosisinvariably
leadstoapooroutlook,gangreneandmultipleamputations.
PrevalenceishigherinmenandpeopleofFarEasternorigin.
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Treatment
Themaingoaloftherapyiseliminationoftobaccosmoking.
Bypasssurgeryisofvariablesuccessowingtothedistalnatureoftheocclusions.
Sympathectomymaybeusefulinincreasingdistalbloodflowandrelievingpain.
Amputationofgangrenousdigitsisfrequentlyrequired.
Familialhypercholesterolaemia(OptionB)isincorrect.Familalhypercholesterolaemiaisageneticdisorderinwhichthe
LDLreceptorisabnormal,leadingtohighcholesterolbloodlevelsandcholesteroldepositionintheskinandtendons
(xanthoma).Typicallycoronarydiseaseisanearlymanifestation,butperipheralvasculardiseasewillmanifestinthose
whosmoke.Whilethisispossible,thepresenceofthrombophlebitispointsmoreinthedirectionofBuergersdisease.
Polyarteritisnodosa(OptionC)isincorrect.Polyarteritisnodosaisavasculitisofsmallormediumsizedarteries.It
typicallyaffectsthevisceralvessels.Patientstendtohaveprofoundfatigue,renalinvolvementandcardiacsymptoms.
Neurologicalinvolvementwillcauseperipheralweakness,strokesandseizures.Patientsmayhavealivedoreticularis.
Noneofthesefeaturesispresentrulingthisanswerout.
Simpleperipheralvasculardisease(OptionD)isincorrect.Simpleperipheralvasculardiseaseismorelikelytopresentin
olderpatientsasittakesmanyyearstodevelop.Furthermore,thrombophlebitis(inflammationandclotting)ofthearteries
isuncommon,ratherthereisatendencytocoldlimbswithoutinflammation.
Temporalarteritis(OptionE)isincorrect.Temporalarteritis(alsoknownasgiantcellarteritis)isavasculitisaffecting
predominantlythebranchesoftheexternalcarotidartery.Patientscomplainofscalptendernessandheadacheswithjaw
claudication.Ifnottreated,acutevisuallosscanoccur.Noneofthesefeaturesispresentrulingthisanswerout.
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Question123of295
A54yearoldmanwithahistoryofsmokingandhypertensionpresentstotheEmergencyDepartmentwithcentral
crushingchestpain,nauseaandsweating.OnexaminationhisBPis104/70mmHg,hispulse85bpmandregular,andhe
lookspale,greyandsweaty.Therearenomurmursonauscultationbuthehascracklesatbothlungbasesconsistentwith
heartfailure.Thetablebelowcontainstheinvestigationresults.
Hb 12.8g/dl
WCC 5.9109/litre
PLT 190109/litre
Na+ 141mmol/litre
K+ 5.0mmol/litre
Creatinine 110mol/litre
ECG STelevationV1V4,STdepressionII,IIIandaVL
Whichoneofthefollowingisthemostlikelyfindingonangiography?
A Totalocclusionofrightcoronaryartery
B 70%stenosisofleftanteriordescendingartery
C Totalocclusionofleftanteriordescendingartery
D 70%stenosisofleftcircumflexartery
E Totalocclusionofleftcircumflexartery
Explanation
STelevationanteriormyocardialinfarction
ThismanissufferingfromanSTelevationanteriormyocardialinfarctionandmostlikelyhasanocclusionofhis
leftanteriordescendingarteryduetoplaquerupture
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Management
Managementofchoiceisprimarypercutaneouscoronaryintervention(PCI),asearlyaspossibleaftertheonsetof
chestpain
StudieshavenowconfirmedthatprimaryPCIissuperiortothrombolysiswithratesofarterialpatencyinmore
than90%ofprocedures,andlowerratesofbleedingcomplications
ECG
LeftcircumflexorrightcoronaryarteryocclusionswouldbeexpectedtoresultineitherlateralorinferiorECG
changes
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Question124of295
An18yearoldstudentisadmittedtotheEmergencyDepartmentafteracollapseinanightclub.Hehasnorecollectionof
theincident,wasassistedbyhisfriendsandhadbeguntoregainconsciousnessbythetimetheambulancehadarrived.On
directquestioningintheEmergencyDepartmentheadmitstotwoprevioussyncopalepisodes.Hedeniesillicitdruguse.
OnexaminationhisBPis123/72mmHg,andhispulseis72regular.Clinicalresultsaregiveninthetablebelow:
Hb 13.2g/dl
WCC 5.3109/l
PLT 199109/l
Na 142mmol/l
K 4.6mmol/l
Creatinine 90mol/l
ECG sinusrhythm,QTinterval0.52s
Adefectinwhichoneofthefollowingionchannelsisthemostlikelycauseofhissymptoms?
A Magnesium
B Sodium
C Potassium
D Chloride
E Calcium
Explanation
Ionchanneldefects
LQT1,2and3mutationsaccountfor45,45and7%ofcasesoflongQTsyndrome,respectively
BothLQT1and2mutationsareassociatedwithdefectivepotassiumtransport,leadingtoadecreaseinpotassium
outflowandmoreprolongeddepolarisation
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LQT8isassociatedwithdefectivecalciumchanneltransportoftenpatientsalsohaveassociatedcongenitalheart
diseaseandbehaviouraldisorders
LQT3mutationisassociatedwithagainoffunctionmutationinsodiumchannels
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Question125of295
A57yearoldmanwithischaemicheartdisease,andarecenttransientischaemicattack,isprescribedclopidogrel.
Howwouldthemechanismofactionofthisdrugbebestdescribed?
A BlocksADPreceptors
B BlocksglycoproteinIIb/IIIareceptors
C Blocksthrombinreceptors
D Blocksthromboxaneproduction
E PotentiatesantithrombinIIIaction
Explanation
TheanswerisBlocksADPreceptors
Clopidogrelblocksplateletadenosinediphosphate(ADP)receptors,whileaspirinblocksthromboxaneproduction.
AspirinandADPreceptorantagonistssuchasclopidogrel,prasugrelandticagrelorhavecomplementaryactionson
platelets,leadingtoeffectiveinhibition.ThisisimportantinACSandwhenperformingangioplasty.
Thefigureshowsthesitesofactionofdifferentantiplateletdrugs.
Figurefrom:BhattDL,HulotJS,MoliternoDJetal.2014.Antiplateletandanticoagulationtherapyforacute
coronarysyndromes.CirculationResearch,114,192943.doi:10.1161/CIRCRESAHA.114.302737
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BlocksglycoproteinIIb/IIIareceptors(OptionB)isincorrect.Thefinalcommonpathwayforplateletaggregationis
throughtheglycoproteinIIb/IIIareceptor.ThemostpowerfulantiplateletdrugsaretheglycoproteinIIb/IIIablockerssuch
asabciximabandtirofiban(therefore,thisoptionisnotcorrect).Theseareintravenousdrugsthataretypically
administeredduringprimaryangioplastywhenpatientshaveasignificantthrombusburden.Previouslytheywereused
routinelyinallcasesandalsotobridgeunstablepatientstoaninvasiveangioplasty.Bleedingcomplicationscanoccur
and,assuch,useisnowrestrictedtobailoutsituationsduringtheinvasiveprocedureitself.
Blocksthrombinreceptors(OptionC)isincorrect.Thrombinispartoftheclottingcascadeandisapowerfultriggerfor
clotformation.Itdrivestheconversionoffibrinogentofibrin,whichtheninterlockstotrapplateletsandRBC.Italso
activatesFactorXIII,whichstabilisesthefibrincrosslinking.AtthesametimeitactivatesFactorsVIIIandV,which
haveafurtherprothromboticeffectsincethesefactorsdrivethrombinproduction.Finally,thrombinupregulatesthe
expressionofGPIIb/IIIareceptors.Drugsthatinhibitthrombinwouldthereforebeusefulinblockingclotting.Bivalirudin
isaclinicallyavailableandcommonlyusedagentthatreversiblyanddirectlybindsthrombintoblockitsaction.
Bivalirudiniscommonlyusedinthecardiaccatheterlaboratoryeitherwith,orasanalternativeto,heparin.Itisrarely
used.
Blocksthromboxaneproduction(OptionD)isincorrect.Asdescribedaspirinblocksthromboxaneproduction.
PotentiatesantithrombinIIIaction(OptionE)isincorrect.Heparinandheparinlikedrugs(enoxaparin,tinzaprin)are
drugsthatpotentiatetheantithrombinIII.Thismoleculenormallyinactivatesthrombin,akeypartoftheclottingpathway.
Heparinsarereferredtoasindirectthrombininhibitors.
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Question126of295
A65yearoldmanisadmittedwithabroadcomplextachycardia.Whichoneofthefollowingfeatureswouldsuggesta
diagnosisofsupraventriculartachycardiawithaberrancyandhelptoexcludeventriculartachycardia?
A Capturebeatsontheelectrocardiogram(ECG)
B Pasthistoryofischaemicheartdisease
C RightbundlebranchblockmorphologywithleftaxisdeviationontheECG
D Temporaryalleviationbycarotidsinusmassage
E Variableintensityofthefirstheartsound
Explanation
Distinguishingventricularfromsupraventriculartachycardia
Ventriculartachycardia(VT)maybedistinguishedfromsupraventriculartachycardia(SVT)byECGfeaturesthat
indicateatrioventricular(AV)dissociation(iethattheatriaandventriclesarenolongerlinkedinrateandrhythm)
ThethreecharacteristicfeaturesofAVdissociationareirregularnotchingoftheQRScomplex,capturebeatsand
fusionbeats
AvariableintensityofthefirstheartsoundinaregulartachycardiasuggestsAVdissociationcausingvariable
fillingoftheventriclesfromtheatria
Atrialfibrillationisthecommonestcauseofvariableintensityofthefirstheartsound
VTdoesnotinvolvetheAVnodeandcannotthereforebeaffectedbyadenosineorcarotidsinusmassage,which
temporarilyblockstheAVnode
Apasthistoryofischaemicheartdiseaseisassociatedwitha>95%chancethatbroadcomplextachycardiaisVT
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Question127of295
A40yearoldhealthymanattendsahealthcheckupclinicpriortoprocuringahealthinsurancepolicy.Heisfoundto
haveafaintsystolicmurmur.Anechocardiogramrevealsabicuspidaorticvalve.
Whatshouldhebetold?
A Hisfamilymembershaveahighchanceofalsohavingabicuspudaorticvalve
B Statinsdelayprogressionofaorticvalvedisease
C Heshouldundergofurtherteststocheckforanyautoimmunedisorder
D Hemayrequireheartsurgeryatalaterdate
E Heshouldstarttreatmentwithlowdoseaspirin
Explanation
TheanswerisHemayrequiresurgeryatalaterdate
Around12%ofaffectedindividualsrequiresurgeryintheirfifthorsixthdecadeforwornoutorcalcifiedvalves.
Hisfamilymembershaveahighchanceofalsohavingabicuspudaorticvalve(OptionA)isincorrect.Bicuspidaortic
valveoccursin12%ofadultsandthereforeisoneofthecommonestformsofcongenitalheartdiseaseinadults.Studies
suggestthatitisautosomallydominantbutwithincompletepenetrance.Thereisafamilialincidenceofaround9%,but
theoccurrencetendstobesporadic.Assuch,familymembersdonothaveahighchanceofalsohavingabicuspidaortic
valve.
Statinsdelayprogressionofaorticvalvedisease(OptionB)isincorrect.Althoughtherewassomeinitiallypositive
observationaldatasupportingtheuseofstatinstopreventtheprogressionofaorticstenosis,multiplerandomised
controlledtrialsdidnotdemonstrateabenefit.(henceoptionBisincorrect).
Heshouldundergofurtherteststocheckforanyautoimmunedisorder(OptionC)isincorrect.Abicuspidaorticvalveis
associatedwithaortopathiessuchasdilatationandcoarctation.Heshouldbescreenedforthis,ratherthanautoimmune
disorderswhichdonotshareanassociation.
Heshouldstarttreatmentwithlowdoseaspirin(OptionE)isincorrect.Therearenodatatosupportlowdoseaspirinin
thissituation.
41969
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Question128of295
A25yearoldmanpresentstotheEmergencyDepartmentwitha1weekhistoryoffeverandmyalgia.Hehadtravelledto
Chile8weeksago.Onexaminationtherearenopositivefindings,althoughthepatientrecollectsthathisrighteyelidwas
swollenforafewweeksafterheleftChile.ECGrevealsnonspecificTwavechangesinallleads.
Whatisthemostlikelydiagnosis?
A Echinococcosis
B Falciparummalaria
C Schistosomiasis
D Toxoplasmosis
E Trypanosomiasis
Explanation
TheanswerisTrypanosomiasis
TrypanosomacruzicausesAmericantrypanosomiasisorChagasdiseaseandisquitecommoninSouthAmerica,
affecting78millionpeopleitisspreadbyreduvidbugs(bloodsuckingbugs).
Thetrypanosomesaretransmittedbyscratchinginfectedfaecesofthebugintoskinabrasionscausedbythebug
duringbloodsucking.
Inacutetrypanosomiasis,thepatientpresentswithfever,myalgia,hepatosplenomegalyandmyocarditis.
Overthecourseofmanyweeks,theinfectionbecomeschronicinthemajorityofcasespatientsareasymptomatic.
Inasmallerproportionofpatients,thereisdelayedventriculardiltationwithheartfailure.Theoesophagusandthe
colonmayalsoenlarge.
Unilateralperiorbitaloedemaandswellingoftheeyelidcanresultfromabugbitearoundtheeyes(Romanassign)
andisclassicaloftrypanosomiasis.
Echinococcosis(OptionA)isincorrect.Echinococcosiscancausemyocarditisbutislesslikelythantrypanosomiasis
becauseofthedescriptionofperiorbitalswelling.
Falciparummalaria(OptionB)isincorrect.Falciparummalariacancausemyocarditisbutislesslikelythan
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trypanosomiasisbecauseofthedescriptionofperiorbitalswelling.
Schistosomiasis(OptionC)isincorrect.Schistosomiasiscancausemyocarditisbutislesslikelythantrypanosomiasis
becauseofthedescriptionofperiorbitalswelling.
Toxoplasmosis(OptionD)isincorrect.Toxoplasmosiscancausemyocarditisbutislesslikelythantrypanosomiasis
becauseofthedescriptionofperiorbitalswelling.
41927
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Question129of295
A28yearoldmanpresentswitha2yearhistoryofincreasingdyspnoeawithstrenuousexertion.Hypertrophic
cardiomyopathyisdiagnosed.Whichisthemostappropriatescreeningmethodforhisbrother?
A Computedtomography(CT)scan
B Exercisetolerancetest
C Ventilationperfusionscan
D Echocardiography
E Geneticscreening
Explanation
Hypertrophiccardiomyopathy
Hypertrophiccardiomyopathyisusuallyfamilial,withautosomaldominanttransmission
Thediagnosisofhypertrophiccardiomyopathyisbaseduponthedemonstrationofunexplainedmyocardial
hypertrophy,whichisbestdoneusingtwodimensionalechocardiography
Thediagnosisrequiresthatmeasurementsofwallthicknessexceedtwostandarddeviationsforsex,age,and
sizematchedpopulations
Inpractice,inanadultofnormalsize,thepresenceofaleftventricularmyocardialsegmentof1.5cmorgreaterin
thickness,intheabsenceofarecognisedcause,isusuallyconsideredtobediagnostic
Lessstringentcriteriashouldbeappliedtofirstdegreerelativesofanaffectedindividual,wheretheprobabilityof
carryingthediseasegeneincreasesfrom1:500to1:2
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Question130of295
A70yearoldladyunderwentmitralvalvereplacementsurgery2yearsago.Sheappearedtomakeagoodrecovery
initially,butnowpresentswithinfectiveendocarditis.
Whatcausalorganismwouldbemostlikelyinhercase?
A Escherichiacoli
B Staphylococcusaureus
C Staphylococcusepidermidis
D Streptococcusfaecalis
E Streptococcusviridans
Explanation
TheanswerisStreptococcusviridans
Organismsthatcauseinfectiveendocarditis
Organismscausinginfectiveendocarditiscanbedividedintothreegroups
nativevalveendocarditis
earlyprostheticendocarditis(<12monthspostsurgery)
lateprostheticendocarditis(>12monthspostsurgery)
Nativevalveendocarditisismainlystreptococcal,predominantlyStreptococcusviridans,althoughStaphylococcus
aureusisalsocommonandoftenaffectspreviouslynormalvalves.Streptococcusviridansoftengainsaccesstothe
valvesbyenteringthebloodstreamfollowingdentalworkorjustbybrushingteeth.
Theprevalencesoforganismscausingnativevalveinfectiveendocarditisareshownintheaccompanyingtable.
Enterococci 1015%
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Other 2025%
Coagulasenegative 13%
EarlyprostheticendocarditisismostcommonlyduetoStaphylococcusepidermidis,withsomeGramnegative
organismsandfungi.S.epidermisisaskincommensualthatgainsaccesstothevalveintheearlypostoperative
phase,usuallywhileinvasivelinesarestillpresent(suchaspacingwiresandcentrallines).Theorganismisindolent
andsoitmaytakesometimetopresentitisusuallypresentwithinthesuturematerialaroundthevalve,whichcan
leadtodehiscence.
Lateprostheticendocarditis,after12months,issimilartonativevalveendocarditis(iemostcommonly
Streptococcusviridans)exceptwithahigherincidenceofstaphylococcalinfection.Therefore,itisclearthattheonly
correctanswerisStreptococcusviridansandtheotheroptionscannotbecorrecthere.
Escherichiacoli(OptionA)isincorrect.Asdescribedthiswouldnotbethemostlikelycauseinthescenariodescribed.
Staphylococcusaureus(OptionB)isincorrect.Asdescribedthiswouldnotbethemostlikelycauseinthescenario
described.
Staphylococcusepidermidis(OptionC)isincorrect.Asdescribedthiswouldnotbethemostlikelycauseinthescenario
described.
Streptococcusfaecalis(OptionD)isincorrect.Asdescribedthiswouldnotbethemostlikelycauseinthescenario
described.
41986
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Question131of295
A61yearoldwomanwithahistoryofischaemicheartdiseaseandCOPDcomestotheEmergencyDepartment.Shetells
youthatshehassufferedanumberofepisodesofpalpitationsandthinkssheisabouttofaint.Inthepastfewdaysshehas
startedacourseoferythromycinforanexacerbationofCOPD.ExaminationrevealsaBPof105/60,pulseis75and
regular.Thereiscoarsewheezeonauscultationofthechest.Whilstyouarelisteningtoherchestyounoticeaself
terminatingshortperiod(15seconds)oftorsadesdepointesonthemonitor.
Investigations(venousbloodgasresult)
Hb 12.9g/dl
WCC 11.2x109/l
PLT 281x109/l
Na+ 137mmol/l
K+ 3.9mmol/l
Bicarbonate 23mmol/l
Creatinine 121micromol/l
Whichofthefollowingisthemostappropriateintervention?
A IVLignocaine
B IVMagnesium
C IVIsoprenaline
D IVAmiodarone
E IVPotassium
Explanation
TheanswerisIVMagnesium
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ItislikelythiswomanhasadegreeofQTprolongationasaresultofherischaemicheartdisease,andthatthishasbeen
furtherexacerbatedbytheuseoferythromycin.InthissituationIVMagnesiumisofvalueinpreventingfurtherepisodes
oftorsades,evenifserummagnesiumlevelsarenormal.ConventionalantiarrhythmicssuchasAmiodaroneand
Lignocaineworsenthelikelihoodoftorsadesinthissituation.IVIsoprenalinetokeeptheventricularrateabove90/minis
aninterimoptionwhenoverdrivepacingisplannedforresistanttorsades.
DrugsknowntoincreasetheriskoftorsadesincludeclassIaandIIIantiarrhythmicagents,Erythromycin,Ketoconazole,
Tricyclicantidepressantsandantipsychotics.
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Question132of295
A72yearoldmanisreviewedinthefallsclinicafter4previousepisodesofsyncope.Carotidsinushypersensitivitywas
suspected,andhehadaprofoundbradycardicresponsetocarotidsinusmassage.Hehasnosignificantpastmedical
historyapartfrommildhypertensionwhichismanagedwithIndapamide.OnexaminationhisBPis142/72mmHg,pulse
is70/minandregular.Routinebloodsareunremarkable.
Whichofthefollowingisthemostappropriateintervention?
A Dualchamberpacemaker
B Fludrocortisone
C Fluoxetine
D Midodrine
E StopIndapamide
Explanation
TheanswerisDualchamberpacemaker
Inbradycardiccarotidsinushypersensitivity,theoptimalinterventiongiventhenumberoffallsthismanhassufferedis
dualchamberpacing.SertralineandFluoxetinemaybeusefulinpatientswhofailtorespondtopacing.Midodrine,(an
alphareceptoragonist)andFludrocortisoneareusefulforhypotensivecarotidsinushypersensitivity.HisBPisatthe
higherendofthenormalrange,assuchthereisnoreasontodiscontinuetheIndapamide.
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Question133of295
Anarticleinaleadingmedicaljournalreads:aninsertionoffivenucleotidesinthegenewasidentifiedasthecauseof
hypertrophiccardiomyopathyinthisfamily.
Whichoneofthefollowingtypesofmutationistheauthorreferringto?
A Frameshiftmutation
B Repeatmutation
C Missensemutation
D Nonsensemutation
E Pointmutation
Explanation
TheanswerisFrameshiftmutation
Asthegroupofnucleotidesinsertedisnotamultipleofthree,themutationchangestheframeinwhichtranslation
occursandhencethenameframeshiftmutation.Theotheranswers(OptionsB,C,DandE)aretherefore
incorrect.
Thegeneticsofhypertrophiccardiomyopathy
Hypertrophiccardiomyopathyaffects1in500peopleandshowsanautosomaldominantpatternofinheritance.At
least11geneshavebeenidentified,whichencodesarcomereorsarcomererelatedproteins.Manydifferenttypesof
mutationhavebeendetected,whichthisquestiontestsyourfamiliaritywith.
Mutationtypes
Amissensemutationisanalterationinanucleotidesequencethatconvertsacodonforoneaminoacidintoa
codonforasecondaminoacid.
AninsertionmutationarisesbytheinsertionofoneormorenucleotidesintoaDNAsequence.
Anonsensemutationisanalterationinnucleotidesequencethatchangesatripletcodingforanaminoacid
intoaterminationcodon.
ApointmutationresultsfromasinglenucleotidechangeinaDNAmolecule.
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AnothertypeofmutationrelevantforMRCPPart1isareadthroughmutation,whichchangesatermination
codonintoacodonspecifyinganaminoacidandhenceresultsinreadthroughoftheterminationcodon.
Repeatmutation(OptionB)isincorrect.Asdescribedthisisnotthecorrectchoicehere.
Missensemutation(OptionC)isincorrect.Asdescribedthisisnotthecorrectchoicehere.
Nonsensemutation(OptionD)isincorrect.Asdescribedthisisnotthecorrectchoicehere.
Pointmutation(OptionE)isincorrect.Asdescribedthisisnotthecorrectchoicehere.
41915
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Question134of295
Apatientattendingthecardiologyclinicrequiresdentaltreatment.
Whichoneofthefollowingconditionsmeritsantibioticprophylaxis?
A Atrialseptaldefect
B Hypertrophiccardiomyopathy
C Patentductusarteriosus
D Alloftheabove
E Noneoftheabove
Explanation
Highrisklesions
Patentductusarteriosuscarriesahighriskofendocarditis,butthereisnorobustevidencethatantibiotic
prophylaxisreducestherisk
Theotherhighrisklesionsaresmallventricularseptaldefectsandaorticregurgitation
Theriskofendocarditisishighestwheretherearehighvelocityjetsofbloodthatdamagetheendothelium
Hypertrophiccardiomyopathymaybeassociatedwithhighvelocityflowintheleftventricularoutflowtract
(LVOT)whenthereismarkedLVOTobstruction,although,inpractice,theriskofendocarditisissmall
Atrialseptaldefects(ASDs)arelargeholesinalowpressuresystemandthereforecarryalowriskof
endocarditisanddonotnormallyrequireprophylaxis
Mitralvalveprolapseonlycarriesappreciableriskwherethereisassociatedmitralregurgitation
Previousrecommendationsforantibioticprophylaxispriortodentalproceduresorinstrumentationofthe
gastrointestinal/genitourinarytractshavebeenwithdrawnasthereislittleevidencethatthesehavebeeneffective
inpreventinginfection
Endocarditismayfollowtransientbacteraemiawithorganismsfromoralorothermucosalflora,butthisismuch
morelikelytoresultfromnormaldailyactivity(chewing,brushingteeth)thanfromavisittothedentistand
antibioticprophylaxisforsucheventsisimpracticalandunnecessary
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Reference
Forthe2008NICEguidelinesonthepreventionofantibioticprophylaxissee
http://www.nice.org.uk/guidance/CG64(http://www.nice.org.uk/guidance/CG64)
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Question135of295
Whichoneofthefollowingstatementsistrueregardingpulsusalternans?
A Itisfoundinberiberiheartdisease
B Thepulseisirregular
C Itisdiagnosedelectrocardiographically
D Itisfoundinassociationwithathirdheartsound
E Itisfoundinpatientswithasmallpericardialeffusion
Explanation
TheanswerisItisfoundinassociationwithathirdheartsound
Pulsusalternansisfoundinpatientswithacuteleftventricularfailure,andthereforemaybefoundinassociation
withathirdheartsound.Itoccursonlyinlowoutputstates.
Pulsusalternans
Pulsusalternansisfoundinpatientswithacuteleftventricularfailure
Alternateweakandstrongpulsesoccur,whichareregularlyplaced
Apathologicalthirdheartsoundisusuallyassociated
Theconditionmaybeassociatedwithheartfailureorpericarditis,forexample,butisnotusuallyseenin
associationwithpericardialeffusion
Beriberiheartdiseaseisahighcardiacoutputstate.ItisassociatedwithlongQT,Twaveinversionandlowvoltage
complexes
Electricalalternans
Electricalalternansisdiagnosedelectrocardiographically
TheamplitudeofQRScomplexesvariesalternately
Itoccursowingtochangesinelectricaldepolarisation,conductionabnormalitiesorcardiacmotion
Itisfoundinberiberiheartdisease(OptionA)isincorrect.Beriberiisassociatedwithahighoutputcardiacfailure
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thereforecannothavepulsusalternans.
Thepuseisirregular(OptionB)isincorrect.Therearealternatingstrongerandweakerpulses,unlikeinatrialfibrillation
wherethepulseisirregularlyirregularinrhythmbutthevolumeofthepulsedoesnotchange.
Itisdiagnosedelectrocardiographically(OptionC)isincorrect.Electricalalternans,diagnosedonelectrocardiography,is
adifferentphenomenon.Thisoccursinpericardialeffusions.
Itisfoundinpatientswithasmallpericardialeffusion(OptionE)isincorrect.Pericardialeffusionscancauseelectrical
alternansastheheartmovesaboutinthepericardialsac.Whenpericardialeffusionscausehaemodynamiceffects,pulsus
paradoxusmaybeseen.
41882
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Question136of295
A52yearoldmanundergoesBruceprotocolexercisetesting6weeksfollowinganuncomplicatedinferiormyocardial
infarction.Hehadechocardiographypriortohisexercisetest,whichdemonstratedabnormalinferiorwallmotion.Heis
currentlyonaspirin75mgod,simvastatin40mgod,lisinopril20mgodandatenolol25mgod.Restingheartrateis72
bpmandbloodpressureis130/70mmHg.Heachieves4minutes15seconds,stoppingsecondarytochestpainand
associatedSTsegmentdepressionintheinferolateralleads.
Whatwouldbethenextstageinhismanagement?
A Adddiltiazemandreviewinclinic
B Arrangeastressechocardiogram
C Increaseatenolol50mgodandrepeattheexercisetest
D Referforcoronaryangiography
E Referforamyocardialperfusionscan
Explanation
TheBruceprotocol
Thepurposeoftheexercisetestpostmyocardialinfarctionistwofold:riskstratificationandpatientselfconfidence
PatientswhoareunabletoperformtwostagesoftheBruceprotocol(<6minutes)areathigherriskofadverse
cardiovascularevents
Thisyoungishmanhasanearlypositiveexercisetest,asexemplifiedbysymptomsandassociatedECGchanges
Investigationandtreatment
Heshouldbereferredforcoronaryangiographytoaccuratelydeterminewhetherhehasprognosticdisease
warrantingcoronaryarterybypassgraftingeg
leftmainstemdisease
proximalthreevesseldisease
proximaltwovesseldiseaseincludingtheleftanteriordescendingartery
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Percutaneousinterventioncanalsobeconsideredifhehasongoingsymptoms(likelyinviewofhissymptomson
exercisetesting)
Increasinghisatenololdosewouldbeasensibleamendmenttohiscurrentmedicaltherapy
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Question137of295
Whichoneofthefollowingantiarrhythmicshasthehighestriskofproducingtorsadesdepointes(TdP)?
A Flecainide
B Lidocaine
C Phenytoin
D Propafenone
E Sotalol
Explanation
TheanswerisSotalol
Amongtheseagentssotalol(aclassIIIagentpredominantlyK+channelblocker),hasthehighestriskof
producingtorsades,whichisapolymorphic,pausedependentventriculartachycardiacausingsyncopeandsudden
cardiacdeath.
PatientsstartedonsotalolshouldhaveanECG23daysafterinitiationlookforprolongationoftheQTinterval.
Flecainide(OptionA)isincorrect.FlecainideisaclassIcagentandhasanalmostzeroriskofproducingTdP.
Lidocaine(OptionB)isincorrect.LidocaineisaclassIbagentandhasanalmostzeroriskofproducingTdP.
Phenytoin(OptionC)isincorrect.PhenytoinisaclassIbagentandhasanalmostzeroriskofproducingTdP.
Propafenone(OptionD)isincorrect.PropafenoneisaclassIcagentandhasanalmostzeroriskofproducingTdP.
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Question138of295
A30yearoldwomanisroutinelyseenbyherGP24weeksintoherfirstpregnancy.Sheiswell,withoutadverse
symptoms.Herbloodpressureis150/96mmHg.Herbaselinebloodpressureatbookingwas136/84mmHg.Noother
abnormalitiesarefound.
Whatdrugtherapywouldyouprescribe?
A Bendrofluazide
B Moxonidine
C Labetalol
D Losartan
E Ramipril
Explanation
TheanswerisLabetalol
Hypertensioninpregnancy
Hypertensioninpregnancyisdefinedasabloodpressure>140/90mmHgorariseof25mmHgofsystolicand/or
15mmHgofdiastolicpressureabovebaseline.
Itisseeninaround10%ofallpregnancies.
Gestationalhypertensionismorecommonthanpreeclampsia,whichisassociatedwithmaternalorgan
dysfunctiontomakethediagnosisofpreeclampsiatheremustalsobeproteinuria(>300mgona24hour
collection).Thiscanonlybetreatedbydeliveryofthebabyifthetimingallows.
Treatment
Firstlineagents,proventobesafeinpregnancy,include
labetalolthisisbecauseithasalongtrackrecordofsafety
methyldopa.
Secondlineagentsinclude
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nifedipine
hydralazine
prazosin.
Bendrofluazide(OptionA)isincorrect.Thiazidesarenotrecommendedforuseinpregnancyowingtotheriskofadverse
effectsonthedevelopingfoetus.
Moxonidine(OptionB)isincorrect.Moxonidineisacentrallyactingantihypertensiveitisavoidedinpregnancydueto
alackofdata.
Losartan(OptionD)isincorrect.Angiotensinreceptorblockersarenotrecommendedforuseinpregnancyowingtothe
riskofadverseeffectsonthedevelopingfoetus.
Ramipril(OptionE)isincorrect.Angiotensinconvertingenzymeinhibitorsarenotrecommendedforuseinpregnancy
owingtotheriskofadverseeffectsonthedevelopingfoetus.
41938
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Question139of295
Toestablishtheaetiologyofpulmonaryhypertension,acardiaccatheterstudywasperformed.Thewedgepressurewas
normal,andthemeanmitralvalvediastolicpressuregradientwas>3mmHgatrest,bothofwhichincreasedwith
exercise.
Fromthesedata,whatistheprobablediagnosis?
A Congenitalheartdisease
B Leftventriculardiastolicdysfunction
C Majorpulmonaryarteryocclusion
D Mitralregurgitation
E Mitralstenosis
Explanation
Mitralstenosis
Thehaemodynamicpatternistypicalofmitralstenosisandmayalsobeseenincortriatriatum,inwhichthereisa
leftatrialmembrane
Alargesystolicpressurewaveinwedgetracingcanbeseeninpatientswithmitralregurgitation
Inaddition,regurgitationofcontrastfromaleftventricularangiogramtotheleftatriumcanbeseen
Theleftventricularenddiastolicpressure(LVEDP)is>15mmHginthosewithLVdiastolicdysfunction
Therewillbe
afocalpressuregradientinalobarorlargerpulmonaryartery
intravascularfillingdefect
ornarrowinginpatientswithmajorpulmonaryarteryocclusionbyclotortumour
Incongenitalheartdisease,therewillbeastepupinoxygensaturationintherightheartandastepdowninthe
leftheart
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Question140of295
A67yearoldlady,postmyocardialinfarction,issuspectedtohavealeftventricularapicalthrombus.Herneurological
statushasdeterioratedandyouwanttoexcludethepossibilitythatacardiacembolushasledtoherneurological
deterioration.
Whatisthemostsuitableimagingtechniqueforconfirmingthisdiagnosis?
A CardiacMR
B Leftventricularangiography
C Multipleuptakegatedacquisitionscanning
D Transoesophagealechocardiography
E Transthoracicechocardiography
Explanation
Imagingtechniques
Althoughanexcellenttechniqueforimagingtheposteriorcardiacstructures(atria,leftatrialappendage,valves
andpulmonaryveins),transoesophagealechoislessusefulforimagingthestructureandfunctionoftheventricles,
especiallytheleftventricularapex,whichisbetterimagedbyconventionaltwodimensionalecho
Atypicalthrombusmaybeapparentoncontrastleftventriculography,butthistechniquecarriesariskof
dislodgingandembolisinginterventricularthrombus
CardiacMRiseffectiveindetectingmuralthrombusbutmaynotbeeasilyavailable
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Question141of295
A3montholdboywithacyanoticheartlesionisfoundtohaveapatentductusarteriosus(PDA).
WhatisthebesttreatmentformaintainingpatencyofthePDApriortosurgery?
A Indometacin
B Surgicalligation
C Angiographicligationofthepulmonaryartery
D ProstaglandinE1administration
E Notreatment
Explanation
Treatingductusarteriosus
TheductusarteriosusinneonatesandinfantsishighlysensitivetovasodilatationbyprostaglandinE1(PGE1)
Patencyoftheductusisnecessaryinpatientswithcyanoticheartdiseaseuntilsurgicalcorrectionoftheheart
problemisundertaken
Thiswillensureadditionaloxygenationoftheblood
AdministrationofPGE1hasbeenfoundtobehighlyeffectiveinsuchcases
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Question142of295
A60yearoldwomanvisitsherGPcomplainingofincreasingshortnessofbreath.Shehasalsosufferedonefainting
episodeoverthepastmonth.Priortothis,shehasbeenwellwithoutsymptomsandwasactive.Clinicalexamination
revealsaBPof132/82mmHg,andanejectionsystolicmurmur.ECGshowsmarkedleftventricularhypertrophywith
strain.Echocardiographyshowsapeakaorticvalvegradientof90mmHganddecreasedleftventricularsystolicfunction.
Whatisthecorrectmanagement?
A Anticoagulation
B Aorticvalvuloplasty
C Regularoutpatientreview
D Routineaorticvalvereplacement(within6months)
E Urgentaorticvalvereplacement(within8weeks)
Explanation
TheanswerisUrgentaorticvalvereplacement(within8weeks)
Aorticvalvereplacement
Thedescriptionisclassicalforaorticstenosis.Thisisthenarrowingoftheaorticvalve,whichistypicallyheardasa
crescendodescrendomurmurattheuppersternaledge.Echocardiographycaninterrogateseverity:inthemodern
era,valveareasof1cm2andameangradientover40mmHg(orpeakflowvelocityover4m/s)areconsidered
severe.Gradientslessthan20mmHgareconsideredmild.
Surgeryforaorticvalvereplacement(AVR)isindicatedinseverelyaorticsymptomaticpatients(angina,exertional
breathlessness,syncope),astheriskofsuddendeathincreasesdramaticallywiththeonsetofsymptoms.Inpatients
withexertionalsyncopetheriskofdeathinsomeseriesis50%at2years.Theriskofaorticvalvesurgeryis<5%.In
thispatient,withhighrisksymptoms(syncope)andconfirmedsevereAS,itisappropriatetoofferAVRatthe
earliestopportunity.
Patientswhoareasymptomaticaretypicallynotoperateduponunlessthereisanotherindicationforacardiac
operationforexample,coronaryarterybypasssurgery(CABG)Similarly,patientswithmoderateaorticstenosis
whoneedtohaveCABGwilloftenbeofferedsimultaneousAVR,astheriskofredosurgeryatalaterdateishigh.
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Valvuloplastyisusedonlyinpatientswithcriticalaorticstenosiswhoareunfitforsurgery,asthebenefitsareusually
shortlived.Itisperformedwithalargeballoon,whichisinflatedintheaorticvalveandwhichwilltearopenthe
fusedcommissures.
Transcatheteraorticvalveimplantation(TAVI)isnowanacceptedtherapyforpatientswhoareinoperableandwould
otherwisebeturneddownforAVR.CurrentresearchisassessingwhetherTAVIcanbeperformedinmoreroutine,
lowerriskpatients.
Anticoagulation(OptionA)isincorrect.AnticoagulationisnotnormallyusedforAS,unlesstherewasconcomitantAF.
Aorticvalvuloplasty(OptionB)isincorrect.Inthiscase,thepatientappearsfitandwell,withnoindicationthata
temporarysolutionisjustified.
Regularoutpatientreview(OptionC)isincorrectthepatientishavinghighriskfeatures(syncope).
Routineaorticvalvereplacement(within6months)(OptionD)isincorrect.AsdescribeditisappropriatetoofferAVRat
theearliestopportunity,sothisisnotthebestoptionofthoseoffered.
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Question143of295
A50yearoldmanpresentswitheffortrelatedangina.Histotalcholesterolis5.5mmol/litre.Hehasnoothercardiacrisk
factorsandnootherrelevantmedicalhistory.HisGPhasalreadystartedaspirin.HisBPintheclinicoverthepastfew
weekshasbeenintherangeof140155mmHgsystolic.
Whichoneofthefollowingisthemostappropriateinitialtreatment?
A blockerandstatin
B Calciumchannelblockerandnitrate
C Nicorandilandstatin
D Isosorbidedinitrate,blockerandcalciumchannelblocker
E Ivabradineandstatin
Explanation
Theanswerisblockerandstatin
Theblockerwillreducecardiacdemandandthereforereduceangina.
TheScandinavianSimvastatinSurvivalStudyshowedthatastatingiventopatientswithanginapectorisanda
cholesterollevelof5.58.0mmol/litre(212308mg/dl)significantlyreducedtheriskofmyocardialinfarction,
consequentlythisisanessentialpartofanytherapy.
Calciumchannelblockerandnitrate(OptionB)isincorrect.Astatinisanessentialpartofanytherapy.Calciumchannel
blockersshouldbeavoidedinthepresenceofsignificantleftventriculardysfunction.
Nicorandilandstatin(OptionC)isincorrect.NICErecommendseitherablockeroracalciumchannelblockerasfirst
lineoptions.
Isosorbidedinitrate,blockerandcalciumchannelblocker(OptionD)isincorrect.Astatinisanessentialpartofany
therapy.blockersandcalciumchannelblockersshouldnotbecombinedduetoriskofsignificantbradycardia.
Ivabradineandstatin(OptionE)isincorrect.NICErecommendseitherablockeroracalciumchannelblockerasfirst
lineoptions.Nitrates,ivabradine,nicorandil,orranolazinearerecommendedassecondlinetherapies.
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Question144of295
Anelderlymanisadmittedwithsyncope.Healsocomplainsofshortnessofbreathandisdiagnosedashavingaortic
stenosis.Whichoneofthefollowingconditionswhenassociatedwithaorticstenosiswouldindicateapoorprognosis?
A Aorticregurgitation
B Leftventricularfailure
C Electrocardiography(ECG)changes
D Endocarditis
E Valvularcalcification
Explanation
Aorticstenosis
Symptomatic
Theprognosisofsymptomaticaorticstenosisispoor,witha50%survivalofonly1to2years
Approximatelyhalfofthedeathsareduetorelentlesshaemodynamicdeterioration,andtheremainderaresudden
andunexpected
Asymptomatic
Theprognosisofasymptomaticbuthaemodynamicallysevereaorticstenosisissomewhatbetter
However,olderpatientswithapeakvelocityof4m/sormoreacrosstheaorticvalvearelikelytobecome
symptomaticinaperiodof2yearsorless
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Question145of295
Apatientpresentswithcongestiveheartfailure.
Whichdrugmaybeeffectiveinreducingmortalityoutsidetheacutesituation?
A Enalapril
B Aspirin
C Digoxin
D Furosemide
E Lidocaine
Explanation
TheanswerisEnalapril
Anumberofstudieshaveconclusivelydemonstratedthatreductioninleftventricularafterloadprolongssurvival
ratesincongestiveheartfailure:thisisbestachievedbyvasodilatorssuchasangiotensinconvertingenzyme(ACE)
inhibitors,egenalapril,andangiotensionIIreceptorantagonists(ARBs),egcandesartan.Thesedrugsblockthe
formationoractionofangiotensinIIandthusreducebloodpressureandafterloadovertimethisleadstoan
improvementinleftventriculardimensionsandfunction.Thereisstrongevidencetoshowthesedrugsareassociated
withamortalitybenefit.
Aspirin(OptionB)isincorrect.Aspirinisindicatedonlyincasesofcoronaryocclusionormyocardialinfarctionpatients
withcardiomyopathieswithpoorventricularfunctionbutunobstructedcoronaryarteriesshouldnotbegivenaspirindue
tothepotentialsideeffects.
Digoxin(OptionC)isincorrect.Standarddrugslikedigitalis,whileamainstayofthetreatmentofexacerbationsofheart
failure,havenotbeenshowntoimprovesurvivalrates.
Furosemide(OptionD)isincorrect.Standarddrugslikediuretics,whileamainstayofthetreatmentofexacerbationsof
heartfailure,havenotbeenshowntoimprovesurvivalrates.Infact,loopdiureticuseisassociatedwithworseoutcomes
anditisrecommendedtheyarestoppedwhenthepatientisfullystabilisedandeuvolaemic.
Lidocaine(OptionE)isincorrect.Lidocaineandotherantiarrhythmicagentsareusefulonlywhenthereisarrhythmia
associatedwithheartfailurethereforeaninappropriatechoicehere.
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Question146of295
A70yearoldwomanpresentstothepreoperativeorthopaedicclinicbeforehipreplacement.Shehassuffereda
myocardialinfarction4yearsearlierandismanagedwithaspirin75mgdaily,ramipril10mgdailyandatorvastatin40mg
daily.Thereisnohistoryofangina,butsheisonlyabletowalkaround50yardsduetohippain.Onexaminationshe
lookswell,andherBPis145/80mmHgwithapulseof75bpm.Clinicalresultsaregiveninthetablebelow:
Hb 14.0g/dl
WCC 5.9109/l
PLT 180109/l
Na+ 140mmol/l
K+ 5.0mmol/l
Creatinine 130mol/l
Whichoneofthefollowingisthemostappropriateinvestigationtoassesshersuitabilityforsurgeryfromthepointof
viewofhercardiovascularstatus?
A 12leadECG
B Treadmillstresstest
C Echocardiogram
D Dobutaminestressecho
E Cardiacangiography
Explanation
Dobutaminestressecho
Dobutaminestressechosimulatestheeffectofexerciseontheheartinpatientswhoareunabletoundertakea
stresstest
Dobutamineisgivenviaivinfusion,andECGmonitoringwithechocardiographyisundertakenbothatrestandat
thepointofmaximalstimulation
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Patientsarerecommendedtodiscontinueblockadeifpossibleforaround3daysbeforetheprocedure,asthe
negativelyinotropicandchronotropiceffectsofblockadecanblunttheeffectsofthedobutamineinfusion
12leadECGwillnotprovideanyinformationoncardiacperformanceunderischaemicstress
Treadmillexercisetestisnotrecommendedbecauseinviewofthispatient'sorthpaedicconditionsheishighly
unlikelytobeabletoexercisewellenoughtogenerateischaemia
CardiacangiographywouldbeanalternativeifforsomereasonDobutaminestressECHOwasunavailable
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Question147of295
A46yearoldmanisadmittedwithatachycardia.Hehasnopreviousmedicalhistoryofnote,butadmitstoexcessiveuse
ofalcoholandcaffeineassociatedwithaparticularlystressfulperiodatworkduringhisjobasabondtrader.On
examinationhisBPis122/80mmHg,hispulseis180bpm.Hischestisclearandtherearenosignsofcardiacfailure.The
tablebelowshowstheinvestigationresults.
Hb 12.1g/dl
WCC 5.6109/litre
PLT 190109/litre
Na+ 139mmol/litre
K+ 4.8mmol/litre
Creatinine 110mol/litre
ECG Narrowcomplextachycardia,rate180bpm
Hehastriedswallowingofcrushedicetonoeffect,6and12mgofadenosineivwithnoeffect.Whichoneofthe
followingisthemostappropriate,nextmanagementstep?
A iv12mgadenosine
B ivamiodaroneloading
C ivatenolol
D ivverapamil
E ivflecainide
Explanation
Managementoftachycardia
Itisappropriatetotry12mgivadenosinebeforemovingontoanalternativetherapy
Verapamilorshortactingblockers,suchasesmolol,arebothappropriatealternativeagentsforachievingsinus
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rhythm
Flecainideisusefulforchemicalcardioversionofparoxysmalatrialfibrillationinpatientswithnohistoryof
underlyingischaemicheartdiseaseivamiodaroneisareasonablealternative
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Question148of295
A52yearoldwoman,withapriorhistoryofrheumaticfever,presentswithshortnessofbreathonstrenuousexertion
whileworkingasalandscapegardener.Sheisinpermanentatrialfibrillationandisonlongtermwarfarinanddigoxin
(125goncedaily).Clinicalexaminationrevealshertobeinatrialfibrillationatarateofaround150bpm.Echo
demonstratespreservedleftventricularfunction,aheavilycalcifiedmitralvalvewithmoderatemitralstenosis(mitral
valvearea1.5cm2)andmoderatemitralregurgitation.Herleftatriumisdilated.
Whatisthemostappropriateinitialtreatmentoption?
A Amiodarone
B Atenolol
C DCshock
D Mitralvalvereplacement
E Percutaneousmitralvalvotomy
Explanation
Mitralvalvedisease
Thiswomanhasmoderate,mixedmitralvalvediseaseandthereforesurgeryisnotcurrentlyindicateditmay,
however,berequiredlateriffeaturesofleftheartfailureprogress
Evenifthemitralstenosisweretobesevere,thepresenceofheavycalcificationofthevalveandconcomitant
mitralregurgitationwouldprecludepercutaneousvalvotomy
Sheisinpermanentatrialfibrillationandassuch,bydefinition,sinusrhythmcannotberestored(asopposedto
persistentorparoxysmal)
Betterratecontrolisrequired
Digoxinonitsownmaynotcontrolcatecholaminedriventachycardia(egduringexertion)
Amiodarone,whileeffective,wouldnotbethefirstchoiceforthisyoungpatientworkingoutdoorsbecauseofits
sideeffectprofile
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Question149of295
AnelderlymanisadmittedtotheICUandputonintermittentpositivepressureventilation.
Whichoneofthefollowingstatementsistruewhencomparedwithspontaneousventilation?
A Lungvolumesaredecreased
B Pulmonaryvascularresistanceisdecreased
C Systemicbloodpressurerises
D Venousreturnandcardiacoutputfall
E Intrathoracicpressureisdecreased
Explanation
TheanswerisVenousreturnandcardiacoutputfall
Answeringthisquestionrequiresanawarenessofthecardiopulmonarycirculation.Recallthatinthenormal
situation,inspirationincreasesvenousreturnandincreasescardiacoutput.Whenlungpressuresareelevated,suchas
duringpositivepressureventilation,venousreturnwillfall,whichwillreducecardiacoutput.Thiswillreduceblood
pressure(OptionC).
Intermittentpositivepressureventilation
Effectsofincreasedlungvolume
Lungvolumesaredecreased(OptionA):duringintermittentpositivepressureventilation(IPPV),lungvolumesare
significantlyincreasedwhencomparedwithspontaneousventilation
Pulmonaryvascularresistanceisdecreased(OptionB):alargetidalvolumecausesariseinpulmonaryvascular
resistance,whichmayleadtopulmonaryhypertensionand/orrightventricularcompromise
Theoverinflatedalveolicausecompressionofthealveolarbloodvessels
Moreover,theresultantincreaseinrightventriclevolumemayimpedeleftventricle(LV)filling(ventricular
interdependence)
Hyperinflationalsoleadstoprostaglandinrelease,whichmaybeaprotectivemechanismagainstlunginjury
Effectsofincreasedintrathoracicpressure
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Intrathoracicpressureisdecreased(OptionE):theintrathoracicpressureisincreasedatallpointsintherespiratory
cycle
InspirationduringIPPVincreasesintrathoracicpressureandsoincreasesrightatrialpressurerelativeto
atmosphericpressure,thereforeleadingtodecreasedvenousreturn
TheincreasedintrathoracicpressurealsodecreasesthegradientacrosstheLVthatithastoworkagainst,which
resultsinadecreasedafterload.Boththeseeffectsreduceintrathoracicbloodvolume
Lungvolumesaredecreased(OptionA)isincorrect.Asdescribed,lungvolumesincrease.
Pulmonaryvascularresistanceisdecreased(OptionB)isincorrect.Asdescribed,pulmonaryvascularresistanceincreases.
Systemicbloodpressurerises(OptionC)isincorrect.Asdescribed,bloodpressureisreduced.
Intrathoracicpressureisdecreased(OptionE)isincorrect.Asdescribed,intrathoracicpressureincreases.
41855
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Question150of295
IntheCardiologyOutpatientsDepartment,a50yearoldobesewomanwasnoticedtohaveasystolicmurmurloudestat
theapex.Isometricexercisebyhandgripintensifiedthemurmur.
Whatisthemostlikelycauseofhermurmur?
A Aorticstenosis
B Hypertrophicobstructivecardiomyopathy
C Mitralregurgitation
D Atrialseptaldefect
E Tricuspidregurgitation
Explanation
TheanswerisMitralregurgitation
Isometrichandgripexercisesincreasebloodpressureandafterloadsignificantly.Therefore,murmurscausedbythe
backwardflowofbloodwillbeaccentuated:aorticregurgitation,mitralvalveregurgitation,mitralvalveprolapse
andventricularseptaldefect.
Themurmurofmitralregurgitationisintensifiedbyisometricexerciseandthushelpstodifferentiateitfromother
systolicmurmurs.
Suddenstandingandamylnitritedecreasethemurmur.
Inmitralprolapse,handgripcausesincreasedleftventricularvolume,whichdelaystheclickandthemurmur.
Aorticstenosis(OptionA)isincorrect.ThemurmurofASisreducedbyhandgripexercisessincetheincreasein
afterloadreducesthegradientpressurebetweentheLVandtheaorta.
Hypertrophicobstructivecardiomyopathy(OptionB)isincorrect.ThemurmurofHOCMisreducedbyhandgrip
exercisessincetheincreaseinafterloadreducesthegradientpressurebetweentheLVandtheaorta.
Atrialseptaldefect(OptionD)isincorrect.Thisisnotthemostlikelycauseofthefindingsdescribed.
Tricuspidregurgitation(OptionE)isincorrect.Thisisnotthemostlikelycauseofthefindingsdescribed.
41925
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Question151of295
Whichoneofthefollowingconditionsismostlikelytoproduceawide,relativelyfixedsplitofS2?
A Congestivecardiacfailure
B Leftbundlebranchblock
C Moderateventricularseptaldefect
D Rightbundlebranchblockwithheartfailure
E WolffParkinsonWhitesyndrome
Explanation
TheanswerisRightbundlebranchblockwithheartfailure
Inanormaladult,S2issplitduringinspiration,andsynchronousduringexpiration.Thisisbecauseduringinspiration
thereisincreasedvenousreturntotherightheart,whichdelaystheclosureofthepulmonaryvalve(P2)relativeto
theaorticvalve(A2).
Awide,fixedsplitofS2istypicallyassociatedwithanatrialseptaldefect,butthisisnotoneoftheoptionshere.
Youarethereforerequiredunderstandtheunderlyingphysiologyandconsideriftheseothercausesorcombinations
cancausethisphenomenon.
Inthiscase,rightbundlebranchblockwidensthesplit,andheartfailuremakesthesplitfixed.Heartfailurecan
reducethephasicchangesinventricularvolumewithventilationduetoshallowbreathingwithcongestedlungsand
hencefixesthesplit.
Congestivecardiacfailure(OptionA)isincorrect.Congestivecardiacfailurealonewillnotproducethispattern.
Leftbundlebranchblock(OptionB)isincorrect.ParadoxicalsplittingsplitduringexpirationiscausedbydelayedLV
emptyingaswithleftbundlebranchblockandaorticstenosis.
Moderateventricularseptaldefect(OptionC)isincorrect.Incasesofmoderateventralseptaldefects,thewideningis
attributabletodelayedP2,butitisnotfixed.
WolffParkinsonWhitesyndrome(OptionE)isincorrect.InWolffParkinsonWhitesyndromeandothercausesof
electricaldelayofleftventricularconduction,includingleftbundlebranchblock,thereisanarrowlysplitS2(ieA2and
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P2becomeclosertogether).
41918
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Question152of295
A70yearoldmanrevertstoatrialfibrillationafterseveralattemptsatcardioversion,butremainssymptomaticdespite
ratecontrolwithdigoxinandmetoprolol.Hedevelopedpulmonaryfibrosiswithamiodarone.
Whichofthefollowingwillbethenextstepinthemanagementofthispatient?
A Switchmetoprololtoamlodipine
B Doublethedoseofdigoxin
C Radiofrequencypulmonaryveinisolationwithablation
D Makeanotherattemptatcardioversion
E Implantacardioverterdefibrillator
Explanation
TheanswerisRadiofrequencypulmonaryveinisolationwithablation
Managementofatrialfibrillation
Itisnotalwayspossibletorestoreandmaintainsinusrhythminpatientswithatrialfibrillation(AF)
Ifsinusrhythmcannotbemaintained,treatmentshouldbedirectedtowardscontrollingtheheartratewithdigoxin,
blockers,ratelimitingcalciumchannelblockers(verapamilordiltiazem)oramiodarone
Betablockersandcalciumchannelblockersareoftenmoreeffectivethandigoxinatcontrollingtheheartrate
duringexercise
Forpatientswhoremainpoorlycontrolleddespitemedicaltherapy,radiofrequencypulmonaryveinisolationwith
ablation(optionC)isnowseenasthetreatmentofchoiceforatrialfibrillationcessationNICErecommendsthis
whenpatientshaveongoingsymptoms
TherearemanydifferenttypesofAFablationpulmonaryveinisolationinvolvesablationoftheatrialtissuethat
extendsintothepulmonaryveins.ThistissueisoftenatriggeringfactorforAF
Switchmetoprololtoamlodipine(OptionA)isincorrectamlodipinehasnoratecontrollingpropertiessinceit
predominantlyhasavasodilatingeffectreducingbloodpressure,amlodipinetypicallycausesareflextachycardia.
Doublethedoseofdigoxin(OptionB)isincorrectthisstategyislesseffectivethanradiofrequencyablation.
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Makeanotherattemptatcardioversion(OptionD)isincorrect.Anotherattemptatcardioversionisunlikelytohelpsince
multipleattemptshavealreadybeenmadeandhavebeenunsuccessful.
Implantacardioverterdefibrillator(OptionE)isincorrectimplantabledefibrillatorshavenodirectroleinthe
managementofAF.
41852
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Question153of295
A67yearolddiabeticisadmittedwithchestpainradiatingtohisleftshoulderandjaw.Heisamoderatesmoker.Serum
cholesterolandLDLlevelsareraisedandtheECGshowsSTdepressionintheinferolateralleads.
Whatwouldbethemostappropriatenextmanagementsteps?
A Transferthefollowingdayforcoronaryangiographyfollowedbyangioplasty
B Thrombolysiswithstreptokinase,clopidogrelandaspirin
C Oralaspirin,clopidogrelandatenolol
D Glyceryltrinitrate,LMWH,aspirin,clopidogrelandatorvastatin
E Tissuetypeplasminogenactivator,aspirin,warfarinandsimvastatin
Explanation
TheanswerisGlyceryltrinitrate,LMWH,aspirin,clopidogrelandatorvastatin
Theacutemanagementofacutecoronarysyndromesincludesanantiischaemicagent(GTN),twoantiplatelet
agents(aspirinandclopidogrel)andanantithrombotic(LMWH).Riskfactorsshouldbemanaged,inthiscasewith
astatin(atorvastatin).
Transferthefollowingdayforcoronaryangiographyfollowedbyangioplasty(OptionA)isincorrect.Althoughthe
patientislikelytoundergocoronaryangiographylater,thequestionasksforthenextmanagementstep.
Thrombolysiswithstreptokinase,clopidogrelandaspirin(OptionB)isincorrect.Thrombolysisisnotindicatedin
NSTEMI.
Oralaspirin,clopidogrelandatenolol(OptionC)isincorrect.Thisoptiondoesnotincludeanantithrombiticagent,and
GTNisfirstlineasanantiischaemicinacutechestpain.
Tissuetypeplasminogenactivator,aspirin,warfarinandsimvastatin(OptionE)isincorrect.Thrombolysisisnotindicated
inNSTEMI.
41872
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Question154of295
Whichoneofthefollowingfeaturesismorecommoninconstrictivepericarditisthanincardiactamponade?
A Pulsusparadoxus
B Kussmaulssign
C Prominentxtrough
D 4chamberdiastolicequilibrium
E Hypotension
Explanation
Featuresofconstrictivepericarditis
Aninspiratoryincreaseinvenouspressure(Kussmaulssign)andasteepydescentinthejugularpulseare
featuresofconstrictivepericarditis
Pericardialknockinearlydiastoleisoftenseeninconstrictivepericarditis
Bothconditionscausefailureofeithersideoftheheartandthediastolicpressureinallcardiacchambersareequal
Aparadoxicalpulseandprominentxtroughinthejugularpulsearemorecommonintamponadethanin
constrictivepericarditis
1585
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Question155of295
A70yearoldwomanisadmittedtohospitalwithaswollenleftleg4weeksafterundergoinganelectivetotalhip
replacement.AnabovekneeDVTisdiagnosedbyultrasound.Sheisinsinusrhythmat60bpmandherbloodpressureis
160/80mmHg.Sheiscommencedontheappropriatedoseoflowmolecularweightheparinandwarfarinloading.The
followingdayshebecomesacutelyshortofbreath.Examinationrevealsarestingtachycardia(110bpm)withblood
pressureof80/50mmHg.Herjugularvenouspressureiselevatedat7cmabovethesternalnotch.Arterialbloodgas
measurementrevealshertobehypoxaemicwithapa(O2)of7kPa.Echocardiographyrevealstherightventricletobe
severelyimpaired.
Whatwouldbethefirstlinetherapyafteradministeringhighflowoxygen?
A Aspirin
B Intravenousheparin
C Surgicalembolectomy
D Thrombolysiswithreteplase
E Venacavalfilter
Explanation
TheanswerisThrombolysiswithreteplase
Thispatienthasclinicalfeaturesofamassivepulmonaryembolusandtheeventisconsistentwithrecentsurgery
andconfirmedDVT.
MassivePEcausessignificantobstructionofthepulmonaryarteriescausinghaemodynamiccompromisenamely
shockorsystemichypotension(systolicbloodpressure<90mmHgoradropof>40mmHgfor>15min)
Thosepatientswiththesefeaturesshouldbeconsideredforthrombolysisasitisnotonlylifesavingbutwill
reducethelongtermcomplicationsofpulmonaryhypertension.
ThepresenceofsignificantRVimpairment(therightventricleisunabletopumpagainsttheclot)isoftena
decidingfactortoproceedtothrombolysis.
Treatment
Theinitialtreatmentofchoiceisthrombolysisusingarecognisedprotocol.
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Whilstsheisonly4weeksoutfromherhipreplacement,thebenefitsofthrombolysiswouldoutweightherisksin
thiscase.
Inotropicsupportandthejudicioususeoffluidsmayalsoberequiredintheinterim.
Subsequentintravenousunfractionatedheparinshouldthenbecommenced.
Aspirin(OptionA)isincorrect.AspirinhasnoroleintreatmentofPE.
Intravenousheparin(OptionB)isincorrect.IVheparinmaybegivenafterthrombolysisbutaloneitwillnotchangeher
prognosisatthispoint.
Surgicalembolectomy(OptionC)isincorrect.Surgicalembolectomyisnottypicallyperformedintheacutesituation
catetherbasedclotbreakdowncanbeperformedasanalternative.
Venacavalfilter(OptionE)isincorrect.AvenalcavalfiltercouldbeconsideredforrecurrentPEsbutitisnotthecorrect
answerinthisacutesituation.
41936
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Question156of295
A49yearoldwomancomestotheCardiologyClinicforreview.Shehasbeeninvestigatedforpalpitationsandiscoming
totheclinictogetherresults.ApasthistoryofasthmamanagedwithhighdoseSeretideandMonteleukastisnoted.Sheis
nowanonsmoker.ExaminationintheclinicrevealsaBPof135/80mmHg,pulseis75/min,sinusrhythm.Herchestis
clearapartfromsomemildwheezing.
Investigations
Hb 13.5g/dl
WCC 7.4x109/l
PLT 197x109/l
Na+ 138mmol/l
K+ 4.5mmol/l
Creatinine 110micromol/l
ECHO Normalejectionfraction,nostructuralheartdisease
MultipleepisodesofAF,thelongestforaperiodof15minutesduringthenight
24hrtape
Whichofthefollowingisthemostappropriateinterventionasprophylaxis?
A Amiodarone
B Bisoprolol
C Digoxin
D Flecainide
E Verapamil
Explanation
TheanswerisFlecainide
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WhilstBisoprololremainsanoptioninCOPD(sincestudiesshowthattheeffectonlungfunctionisverymodestand
potentiallysubclinical),insevereasthmaitismoreappropriatetotrialalternativesfirst.Flecainideisaclass1Coptionin
patientswithoutstructuralorischaemicheartdiseaseandisthereforethefirstchoicehere.Duetolongtermadverse
effectsAmiodaronewouldremainasecondorthirdlineagentafterFlecainide,thenBisoprolol.DigoxinandVerapamil
aremosteffectiveasratecontrolagents.
37795
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Question157of295
Whichoneofthefollowingisthemostappropriateinitialinvestigationfora66yearoldmanwithrightsidedchestpain
andleftbundlebranchblock(LBBB)onthe12leadECG,(unchangedfromECG3monthsearlier)?
A Cardiacmagneticresonanceimaging
B Exercisetreadmilltesting
C Invasivecoronaryangiography
D Nuclearperfusionscanning
E Stressechocardiography
Explanation
TheanswerisStressechocardiography
Leftbundlebranchblock
NICEguidancerequiresassessmentofthepretestprobabilityofsignificantcoronarydisease.Thepatienthas
LBBB,whichraisesthepossibilityofimportantCADbuthehasatypicalsymptoms.Overallthisplaceshiminan
intermediateriskprofilewhichwouldrequireischaemiatesting.Averylowriskwouldrequirenoinvestigations,
whilealowriskwouldsuggestusingCTcoronaryangiography(notanoptioninthisquestion).Theaimistoavoid
performingunnecessaryinvasivecoronaryangiography.
Stressechocardiographyisthemostappropriateinvestigationinthissetting.
Yourlocalexperienceofthemanagementofchestpainwillalsodependupontheservicesandexpertiseavailable
locally.
Cardiacmagneticresonanceimaging(OptionA)isincorrect.Cardiacmagneticresonanceimagingaloneprovidesdetails
aboutthecardiacstructureandtissuesonlyifastresscomponentisadded(egadenosinestressperfusionMRI)would
ischaemiabedetected.
Exercisetreadmilltesting(OptionB)isincorrect.ExercisetreadmilltestingisunhelpfulinpatientswithLBBB,asthe
ECGisnotreadilyanalysedfurther.
Invasivecoronaryangiography(OptionC)isincorrect.NICEguidanceadvisesagainstperformingunnecessaryinvasive
coronaryangiography.
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Nuclearperfusionscanning(OptionD)isincorrect.AbnormalseptalcontractioninLBBBoftenproducesfalsepositives
onnuclearperfusionscans.
42028
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Question158of295
A32yearoldmanisbroughttotheEmergencyDepartmentinacollapsedstatehavingsustainedaprecordialstabwound.
Whichofthefollowingcardiacvalvesismostlikelytohavebeeninjured?
A Aorticvalve
B Tricuspidvalve
C Pulmonaryvalve
D Mitralvalve
E Thebesianvalve
Explanation
TheanswerisTricuspidvalve
Toanswerthisquestionrequiresanawarenessthattherightsideoftheheartisthemostanteriorpartoftheheart.
Thetricuspidvalveisthemostanteriorvalveandthereforemostpronetoinjuryduringstabbing.
Precordialstabwound
Thetricuspidvalveisthemostanteriorvalveofthehumanheartandisthemostcommontobeinjuredduringa
stabbingattack
Penetratinginjuriesmaycauselacerationstoanyoftheheartchambersorgreatvessels,anddeathmayresultfrom
haemorrhageorcardiactamponade
Latecomplicationsincludeinfectivepericarditis,valvedamageorintracardiacshunts
Echocardiographyisusefulindiagnosingtheunderlyingproblem
Aorticvalve(OptionA)isincorrect.Theleftsidedvalvesaremoreposterior.
Pulmonaryvalve(OptionC)isincorrect.Theleftsidedvalvesaremoreposterior.
Mitralvalve(OptionD)isincorrect.Theleftsidedvalvesaremoreposterior.
Thebesianvalve(OptionE)isincorrect.TheThebesianvalveisthevalveofthecoronarysinus.
41891
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Question159of295
Whichoneofthefollowingpatientswouldbebestservedbyapermanentpacemaker(PPM)?
A 40yearoldasymptomaticmanwithtypeIseconddegreeAVblockandamaximumdocumentedperiodof
asystoleof1.5s
B 40yearoldmanwithtypeIIseconddegreeAVblockandaventricularrateof45bpmwhenawakeand
asymptomatic
C 40yearoldmanwithLymediseasewithasymptomaticcompleteAVblock
D 40yearoldmanwithchronicasymptomaticbifasicularblockandfirstdegreeAVblock
E 40yearoldman,3daysaftersufferinganacuteanteriorMIandhavingapersistentfirstdegreeAVblockand
oldrightbundlebranchblock
Explanation
Theansweris40yearoldmanwithtypeIIseconddegreeAVblockandaventricularrateof45bpmwhenawake
andasymptomatic
TypeIIseconddegreeAVblockhasahighchanceofprogressingtoasystole(35%)eachyear,andisassociatedwith
suddenandunexpectedhaemodynamicinstability.Consequently,urgentinsertionofaPPMisappropriateeven
withoutsymptoms(ClassIindication).
Theindicationsforpacingcanbecomplexandopentodebate,andcertainlyrequiretailoringtotheindividual
patientandclinicalcircumstancesbutthe2013ESCguidelinesgiveclearadviceandshouldbefollowedforexam
questions.
Allfivescenariosfeaturea40yearoldmanwithapersistent(butinthecaseofoptionCnotpermanent)AVblock.
40yearoldasymptomaticmanwithtypeIseconddegreeAVblockandamaximumdocumentedperiodofasystoleof1.5
s(OptionA)isincorrect.InTypeIseconddegreeAVblockpacingisonlyindicatedifsymptomatic(orifintraorinfra
HisblockfoundatEPS).
40yearoldmanwithLymediseasewithasymptomaticcompleteAVblock(OptionC)isincorrect.TheAVblockof
Lymediseaseisusuallyreversibleifthepatientisasymptomaticcarefulinhospitalmonitoringwouldbeappropriate.
40yearoldmanwithchronicasymptomaticbifasicularblockandfirstdegreeAVblock(OptionD)isincorrect.
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AsymptomaticbifasicularblockwithfirstdegreeAVblock(sometimesreferredtoastrifasicularblock)isnotan
indicationforpacing.
40yearoldman,3daysaftersufferinganacuteanteriorMIandhavingapersistentfirstdegreeAVblockandoldright
bundlebranchblock(OptionE)isincorrect.AVblockpostMIisusuallytransient.Whenitpersists,theindicationsfor
pacingdonotdifferfromtheacutesetting.
41912
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Question160of295
A22yearoldcocaineaddictpresentswithcentralcrushingchestpainafterapparentlysnorting3linesofthedrug.Heis
paleandsweaty.Hisbloodpressureis180/110mmHg.ECGshowsanteriorSTelevationconsistentwithmyocardial
infarction.
Whichoneofthefollowingisthemostappropriatetreatment?
A Thrombolysis
B Heparin
C Percutaneouscoronaryintervention
D Naloxone
E Glycoprotein2b/3ainhibitors
Explanation
Cocaineinducedmyocardialischaemia
Cocaineusehasrecentlybeenimplicatedasacauseofunstableangina
Threepossiblemechanismsbywhichcocaineinducesmyocardialischaemiaare:
increasedmyocardialoxygendemand
decreasedmyocardialoxygensupplysecondarytovasospasmorcoronarythrombosis
directmyocardialtoxicity
Documentedcocaineuseshouldnotbeconsideredtoruleoutunderlyingsignificantcoronaryarterydisease
(CAD),asthedrugmayprecipitatecoronaryvasospasmoracutemyocardialinfarctioninthepatientwith
atheroscleroticCAD
Whereurgentangioplastyisavailable,thisispreferabletothrombolysisasoutcomestudiesshowittobesuperior
5604
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Question161of295
A25yearoldmanwithrightventricularcardiomyopathy,previouslyasymptomatic,hassustainedmonomorphic
ventriculartachycardiaontreadmillexercise.ClinicalexaminationandrestingECGisunremarkable.
Whichoneofthefollowingtreatmentoptionsisconsideredtheusualfirstlineoption?
A Flecainide
B Implantablecardioverterdefibrillator
C Radiofrequencycatheterablation
D Rateresponsive,dualchamberpacemaker
E Sotalol
Explanation
Treatingventriculartachycardia
Sotalol
Amongallantiarrhythmicstested,sotalolhasshownthehighestefficacyintrialssofar
Itisthereforerecommendedasthefirstchoicedrugtopreventarecurrenceofventriculartachycardia(VT)
Othernotes
RadiofrequencyablationisaprocedureformedicallyrefractoryVTinselectedpatientsonly,andthereisno
informationregardingitsefficacyinpreventingsuddencardiacdeath
InpatientswithabortedsuddencardiacdeathandinhighriskpatientswithVTwithcompromisedrightandleft
ventricularfunction,implantablecardioverterdefibrillator(ICD)therapy,mightreducemortality
ThereareproblemswithusingICDinrightventricularcardiomyopathy(wheretheRVmusclemassmightbetoo
thin),sucha
lowRwaveamplitude
highthresholds
leadperforation
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Question162of295
A20yearoldwomancomplainsofrecurrentsyncope.Eachattackhasoccurredafterattendinganaerobicsclass.On
examination,asystolicmurmurisheardwhichworsenswiththeValsalvamanoeuvreandimprovesonsquatting.
Whatcouldbethediagnosis?
A Epilepsy
B Hypertrophicobstructivecardiomyopathy
C Atrialfibrillation
D Aorticstenosis
E Vasovagalattack
Explanation
TheanswerisHypertrophicobstructiveCardiomyopathy
Eachoftheanswersareassociatedwithsyncopalepisodes.Thekeydiscriminatoristheadditionalmurmur(ruling
outEpilepsy,AFandVasovagalattack).Bothaorticstenosisandhypertrophiccardiomyopathy(HCM)areassociated
withanejectionsystolicmurmur.However,thedescriptiongivenisofamurmurthataccentuates(louder)with
Valsalvaandattenuates(quieter)onsquatting.
Valsalvamakesmostmurmursquieterthisistrueofaorticstenosis,pulmonarystenosisandtricuspidregurgitation.
Itdoesthisbyreducingpreloadtotheheartthereforetheventricleisrelativelyunderfilledandsotheejection
murmursarequieter.
However,Valsalvaincreases(makeslouder)themurmurinHCMandmitralvalveprolapse.
Squattingincreasesperipheralresistanceandincreasesventricularfilling.Itbringsoutthemurmursofventricular
septaldefect,aorticstenosisandaorticinsufficiency,andmitralinsufficiency.Sinceperipheralresistanceincreases,
afterloadisincreasedandthereforethereislessgradientbetweentheLVandaorta,sosquattingwillcausethe
murmurofHCMtobecomequieter.StandingfromasquattingpositionwillmeantheHCMmurmurbecomesmuch
louder.
Sinceinthiscasethemurmurismadequieteronsquatting,thenitcannotbeaorticstenosis,butismorelikelytobe
hypertrophiccardiomyopathy.
Hypertrophiccardiomyopathy
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Hypertrophiccardiomyopathywaspreviouslyreferredtoashypertrophicobstructivecardiomyopathy(HOCM).The
obstructivepartwasremovedinrecognitionthattheconditionisaspectrumwherenotallpatientshaveoutflow
tractobstruction.
Symptoms
Dyspnoeaisusuallythemostcommoncomplaintofpatientswithhypertrophicobstructivecardiomyopathy.
However,anginaorsyncopemayalsooccur.
Mostpatientswithpureorpredominantaorticstenosishavegraduallyincreasingobstructionforyearsbutdonot
becomesymptomaticuntiltheirsixthtoeighthdecades.
Examinationfindings
Aleftventricularapicalimpulse,aprominentS4gallopandaharshsystolicejectionmurmuraretypicalfindingsin
thesecases.
Valsalvamanoeuvredecreasesvenousreturntotheheart,whichresultsinasmallerventricularsize,whichinturn
increasesthemurmur.
Anechocardiogramisthediagnosticprocedureofchoice.
Epilepsy(OptionA)isincorrect.Asdescribedthiscanberuledoutbythemurmur.
Atrialfibrillation(OptionC)isincorrect.Asdescribedthiscanberuledoutbythemurmur.
Aorticstenosis(OptionD)isincorrect.Asdescribedthiscanberuledoutasthemurmurismadequieteronsquatting.
Vasovagalattack(OptionE)isincorrect.Asdescribedthiscanberuledoutbythemurmur.
41896
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Question163of295
TheepsilonpotentialisseenontheECGofpatientswithwhichoneofthefollowing?
A Hypertrophiccardiomyopathy
B Restrictivecardiomyopathy
C Rightventriculardysplasia
D RomanoWardsyndrome
E Digoxintoxicity
Explanation
TheanswerisRightventriculardysplasia
Episolonpotentialsareonlyseeninrightventriculardysplasia.Theyarenotpresentintheotherconditionsand,as
such,theremainingoptionsarefalse.Thefigurebelowshowsanepsilonwave.
Rightventriculardysplasia
Theepsilonpotentialisamarkerofrightventricularconductiondelay,andappearsasasharpdeflectionor
blipafterterminationoftheQRScomplexduringtheSTsegmentorupstrokeoftheTwave.Sometimesthe
blipcanbeburiedintheendoftheQRS
Itisseenintherightventricularleads,V1andV2
FontainenamedthewavesepsilonsinceepsilonfollowsdeltaintheGreekalphabet
Rightventriculardysplasiaischaracterisedbythedisplacementofmyocytesbyfat
Thisdelaystheexcitationanddepolarisationofthoseviablemyocytesenvelopedbythefattytissue,andso
leadstoepsilonpotentials
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Hypertrophiccardiomyopathy(OptionA)isincorrect.Epsilonpotentialsarenotseeninhypertrophiccardiomyopathy
Restrictivecardiomyopathy(OptionB)isincorrect.Epsilonpotentialsarenotseeninrestrictivecardiomyopathy.
RomanoWardsyndrome(OptionD)isincorrect.EpsilonpotentialsarenotseeninRomanoWardsyndrome.
Digoxintoxicity(OptionE)isincorrect.Epsilonpotentialsarenotseenindigoxintoxicity.
41889
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Question164of295
A22yearoldstudentisadmittedbyambulancefromalocalnightclub.Hehasnopreviousmedicalhistoryofnoteandis
adopted,soisunawareofhisfamilyhistory.Bystanderswhohaveaccompaniedhimsaythathesufferedsuddencollapse
whiledancing.Bouncersattheclubclaimthattheycouldnotfeelapulseduringhisperiodofunconsciousness.On
admissionhisbloodpressureis120/60mmHg,andpulseis80bpmandregular.TheshapeoftheQRScomplexlooks
normal,althoughthecorrectedQTintervalis0.6s.
Whichoneofthefollowingdiagnosesfitsbestwiththepatientsclinicalpicture?
A Carotidsinussyndrome
B Ecstasyoverdose
C JervellandLangeNielsen(JLN)syndrome
D LongQTsyndromemutationuncharacterised
E Simplesyncope
Explanation
TheanswerisLongQTsyndromemutationuncharacterised
ThismansQTintervalisprolongedwithanepisodeofcollapsethereforeyoushouldconsiderlongQTsyndrome
astheprincipaldiagnosis.
LongQTsyndrome
EpisodesofsevereQTprolongationandtorsadesdepointesventriculartachycardiaincongenitallongQT
syndromemaybeprecipitatedbyincreasedadrenergicdrive(suchasthatfromdancinginanightclub).
TheperiodwithoutapulsewaslikelytobehaemodynamicallyimportanttorsardedepointesVT.
Thispatientisadopted,soitmaybepossiblethatthereisanunknownfamilyhistoryofsuddendeath.
ThemolecularbiologyoflongQTsyndromesisheterogeneous,andanumberofdifferentmutationscoding
forpotassiumorsodiumchannelsmayberesponsible.
Wherespecificmutationsareidentified,antiarrhythmictherapymaybespecificallytargetedtoprovide
optimumtherapy.
Inpatientswhorespondpoorlytomedicaltreatment,animplantabledefibrillatormaybeconsidered.
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Carotidsinussyndrome(OptionA)isincorrect.Incarotidsinussyndromethereishypersensitivityofthecarotidplexus
suchthatcontactwiththeneckproducesintensevagalstimulationwithextremebradycardiaandcollapse.Thehistoryis
typicallyoffaintingwhileturningtheneck,particularlyifwearingastiffcollarshirt,orwhileshaving.
Ecstasyoverdose(OptionB)isincorrect.Ectasyoverdosewouldfeaturehyperthermia,sweating,tachycardia,
hypertension,wakefulnessandmydriasis.Noneoftheseispresenthere.
JervellandLangeNielsen(JLN)syndrome(OptionC)isincorrect.JLNsyndromeisalsoassociatedwithlongQTand
itisaparticularsubtypeofthesyndrome.However,patientswithJLNhavedeafnessinadditiontothecardiacrhythm
abnormalitytherefore,thisisnotthebestanswerforthisscenario.
Simplesyncope(OptionE)isincorrect.Simplesyncopeshouldnotresultinaprolongedpulselessepisodeandthere
shouldbeprodromalfeatures.
41988
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Question165of295
Duringpreoperativeassessment,a67yearoldwomanisfoundtohaveasmallpericardialeffusionlocatedposteriorlyon
routineechocardiography.Electrocardiogram(ECG)isentirelynormal.
Whichoneofthefollowingisthemostappropriatenextstepinhermanagement?
A Cardiaccatheterisation
B Reassure
C Pericardiocentesis
D Diuretics
E Computedtomography(CT)oftheheart
Explanation
Pericardialeffusion
Oncethediagnosisofpericardialeffusionhasbeenmade,itisimportanttodeterminewhethertheeffusionis
creatingsignificanthaemodynamiccompromise
Asymptomaticpatientswithouthaemodynamiccompromise,evenwithlargepericardialeffusions,donotneedto
betreatedwithpericardiocentesisunlessthereisaneedforfluidanalysisfordiagnosticpurposes(eginacute
bacterialpericarditis,tuberculosisandneoplasias)
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Question166of295
Rightventricularmyocardialinfarctionismostlikelytobeassociatedwithwhichoneofthefollowing?
A STsegmentelevationinleadsII,IIIandaVF,withQwavesandTwaveinversionintheseleads
B Occlusionoftheleftcoronaryartery
C Markedpulmonaryvascularcongestion
D Ariseinsystolicbloodpressure
E AbsentKussmaulssign
Explanation
TheanswerisSTsegmentelevationinleadsII,IIIandaVF,withQwavesandTwaveinversionintheseleads
Rightventricularmyocardialinfarction
Rightventricularmyocardialinfarctionusuallyoccursinassociationwithaninferiorwallleftventricular
infarction,asrevealedbyanECG
Thereisusuallyarightcoronaryocclusion
Characteristicclinicalfeaturesincludealowcardiacoutputsyndromewithjugularvenousdistensionbutno
pulmonaryvascularcongestion
Kussmaulssign(increasedjugularvenousdistensionwithinspiration)maybeevident
Occlusionoftheleftcoronaryartery(OptionB)isincorrect.RightventricularinfarctionistypicallycausedbyaRCA
occlusion.
Markedpulmonaryvascularcongestion(OptionC)isincorrect.Pulmonaryvascularcongestioncanoccurwithany
myocardialinfarctionbutismorelikelyinleftcoronaryocclusionswhichaffecttheleftventricle.
Ariseinsystolicbloodpressure(OptionD)isincorrect.Hypotensionismorelikelytooccurinarightventricular
infarction.
AbsentKussmaulssign(OptionE)isincorrect.KussmaulssignisafeatureofRVinfarction.
41894
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Question167of295
A52yearoldmanisadmittedtotheintensivetherapyunitwithleftventricularfailurepostmyocardialinfarction.
Despitepromptactivityincludingangioplastywithinafewminutesoftheonsetofchestpain,hissystolicBPon
admissiontotheunitwasonly80mmHg,withapulseof105bpm.Auscultationofthechestrevealedcracklesuptothe
midzonesonbothsidesconsistentwithcardiacfailure.Theteamdecidetoinsertanintraaorticballoonpumptimedto
coincidewiththedicroticnotch.Whichoneofthefollowingdoesthedicroticnotchreferto?
A Aorticvalveopening
B Aorticvalveclosure
C Mitralvalveopening
D Mitralvalveclosure
E Pulmonaryvalveclosure
Explanation
Effectofintraaorticballoonpump
Thedicroticnotchreferstoasecondaryupstrokeinthedownwardpartofthepulsewave,whichcorrespondswith
closureoftheaorticvalve
Intraaorticballoonpumpsdeflateduringsystolewhichthenincreasesforwardbloodflowbecauseofthe
reductioninafterload
Thepumpthenreinflatesduringdiastole,increasingthebloodflowtocoronaryarteries
20925
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Question168of295
A52yearoldmaleisundergoingexercisetolerancetestingforcoronaryarterydiseasescreeningaftersuffering
indigestiontypepainwhilstplayingsquashwithaworkmate.HereachesstageIIoftheBruceprotocolwhenhisBPis
210/100mmHgandheartrateis170bpm.ECGchangesarenoted.Whichoneofthefollowingisthestrongestindicator
ofunderlyingarterialdiseaseforstoppingthetest?
A HisBPof210/100mmHg
B Hisheartrate
C 3mmSTdepressioninthelateralleads
D Patientrequest
E Ventricularectopicsonthemonitor
Explanation
Discontinuationofexercisetolerancetesting
Hypertensionofgreaterthan250/115mmHgisusuallyconsideredareasontodiscontinuethetest
Adropofmorethan10mmHgbloodpressureinthepresenceofotherevidenceofischaemiaisalsoareasonfor
discontinuingtheexercisetest
Inthepresenceofanachievedheartrateof170bpm,STdepressionof3mmisanentirelyappropriatereasonfor
discontinuingthetest
Ventricularectopics,ratherthansustainedventriculartachycardiaareacceptable,andthetestneednotbestopped
forthese
21353
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Question169of295
A42yearoldmanwiththefeaturesofcongenitalmyotonicdystrophycomestoseeyouforreview.Hehassufferedfrom
mildintellectualimpairment,frontalbaldingtypicalofthediseaseandincreasingmuscleweaknesswithincreasedmuscle
toneoverthepastfewyears.Mostrecentlyhehassufferedfromanumberofepisodesofsyncope.OnexaminationhisBP
is129/70mmHgandhispulse55bpmtherearenoothersignificantfindingsoncardiovascularexamination.Whichof
thefollowingECGfindingsmightyoumostcommonlyexpecttoseeinthiscase?
A ShortPRinterval
B PRprolongation
C LongQTsyndrome
D Bifasicularblock
E Leftbundlebranchblock
Explanation
Congenitalmyotonicdystrophy
PRprolongationisthecommonestfeatureseeninassociationwithcongenitalmyotonicdystrophy
Varyingconductiondefectsmaybeseen,including:
rightbundlebranchblock
leftbundlebranchblock
bifasicularblock
Thesyncopesseenheremayberelatedtoperiodsofcompleteheartblock,anda72hHoltermonitorwouldbethe
nextmostlogicalinvestigationinanattempttocapturethese
Theotherpossibilitywouldbeshortrunsofventriculartachycardia(VT),asmyotonicdystrophyalsoincreases
theriskofparoxysmsofVT(again,itwouldbehopedthatthesewouldbecapturedonaHoltermonitor)
20719
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Question170of295
A58yearoldmansECGshowsacombinationofaprolongedQTintervalwithtallTwaves.
Whatisthissuggestiveof?
A Uraemiaandhyperkalaemia
B Hypocalcaemia
C Hypokalaemia
D Hypermagnesaemia
E Metabolicalkalosis
Explanation
TheanswerisUraemiaandhyperkalaemia
InterpretinganECG
ThemainECGchangeresultingfromhypocalcaemiaisalongQTintervalduetoprolongationoftheSTsegment.
TallTwavesareduetohyperkalaemiaand/oracidosis,whichcanbecausedbyrenalfailure.
Hypokalaemia
Hypokalaemiaiscausedby:
potassiumwastingdiuretics
potassiumwastingdiarrhoea
hypokalaemicperiodicparalysis
ThehallmarkoftheeffectofhypokalaemiaontheECGisthedevelopmentoflargeUwaves(positivedeflection
aftertheTwave).
ThenormalUwaveisproducedbyrepolarisationoftheHisPurkinjesystem.
Hypocalcaemia(OptionB)isincorrect.HypocalcaeamiacausesQTcprolongationbyprolongingtheSTsegmentbutdoes
notaltertheTwaves.SincetheTwavesaretall,hypocalcaemiacannotbetheanswer.
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Hypokalaemia(OptionC)isincorrect.HypokalaemiacausesprolongationofthePRintervalandTwaveflattening.There
isSTdepressionandUwaves.Noneofthesefeaturesispresentsohypokalaemiaisnotthecorrectanswer.
Hypermagnesaemia(OptionD)isincorrect.HypermagnesaemiacausesprolongedPRandQTintervalstheQRSbecomes
prolongedandcompleteAVblockmayoccur.
Metabolicalkalosis(OptionE)isincorrect.MetabolicalkalosiswillcausehypocalcaemiaandthesameECGfeatures.
41888
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Question171of295
A75yearoldmalepatientwithtype2diabetesmellitusisbroughttoA&Ecomplainingofchestpain.Hewasdischarged
2daysagoafteranuneventfulhospitalcoursefollowinganacuteMI1weekspreviously,havingbeensuccessfully
thrombolysedwithstreptokinase.AnECGinA&EshowsSTelevationsinleadsV1V3.Thepatienthasbeengiven10U
reteplaseiv.
Whichofthefollowingstatementsiscorrectregardingthefurthermanagementofthispatient?
A Thedoseofreteplaseshouldnotberepeated
B Streptokinasewouldhavebeenabetterchoiceinthissituation
C Antithrombinslikeheparinshouldnotbeadministeredwithreteplase
D Clinicaltrialsshowthatstreptokinasegivesthemaximumthrombolyticpatencyrates
E Thethrombolyticagentassociatedwiththeminimumriskofhaemorrhagicstrokeisstreptokinase
Explanation
TheanswerisThethrombolyticagentassociatedwiththeminimumriskofhaemorrhagicstrokeisstreptokinase
ThispatienthassufferedanSTelevationmyocardialinfarction.Reperfusionmustbesoughtwithin12hofonsetof
symptoms.Themoderntreatmentofacutemyocardialinfarctionisnowprimaryangioplasty:coronarybloodflowis
restoredbyopeningthevesselusingaballoonandstent.However,thrombolyticsremainimportantforpatientswho
cannotreachthecatheterlaboratorywithin2hoffirstmedicalcontact.ThrombrolysisshouldbeconsideredifPCIis
notavailableandtransfertoaPCIisnotpossible.
ThethrombolyticagentsapprovedforuseintheUKbytheNationalInstituteofClinicalExcellence(NICE)are
streptokinase,reteplase,tenecteplaseandalteplase.Streptokinaseisgivenasanivinfusionover1h.Tenecteplaseis
givenasasinglebolusinjection.
Thedoseofreteplaseshouldnotberepeated(OptionA)isincorrect.Reteplaseisgivenastwoivboluses30minapart.
Alteplaseisgiveneitherasanacceleratedregimen(onebolusfollowedbytwoivinfusions)orasastandardregimen(one
bolusandfiveinfusions).
Streptokinasewouldhavebeenabetterchoiceinthissituation(OptionB)isincorrect.Ifstreptokinasehadbeengiven
morethan5dago,neutralisingantibodiesmaypreventtheefficacyofaseconddoseandanotheragentshouldbeused.
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Antithrombinslikeheparinshouldnotbeadministeredwithreteplase(OptionC)isincorrect.Hepariniscoadministered
withreteplaseandalteplase,butnotwithstreptokinasethisiswhyoptionCisnottrue.
Clinicaltrialsshowthatstreptokinasegivesthemaximumthrombolyticpatencyrates(OptionD)isincorrect.Clinical
trialshaveshownthatthemaximum90minpatencyrateisobtainedwithreteplase.Mosttrialshaveshownnosignificant
differenceinmortalityratesbetweenthevariousthrombolyticagents.However,GUSTO1showedthattheaccelerated
alteplaseregimenwassuperiortostreptokinase.ASSENT2foundalmostequal30dmortalityratesassociatedwiththe
tenecteplaseandacceleratedalteplaseregimens.Thusacceleratedalteplaseandtenecteplasearebelievedtobesuperiorto
streptokinase.Thethrombolyticagentwiththeminimumriskofcausinghaemorrhagicstrokeisstreptokinase.
41883
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Question172of295
A50yearoldmanwithnopreviouscardiovascularhistorycomestotheEmergencyDepartmentafterreferralfromhis
GP.HeattendedtheGPsurgerywithpalpitations,whichwereextremelyrapidandirregular.Itisnow0900handhetells
youthepalpitationsbeganthepreviousmorningafteraheavydrinkingsessionwithafriendfromwork.Thereisno
historyofsmoking,cardiovasculardiseaseorpreviousmyocardialinfarctionheplayssquashtwiceperweekandcycles
towork.OnexaminationhisBPis125/77mmHgandhispulseis140bpm,irregular.Heisnotincardiacfailure.Clinical
resultsaregiveninthetablebelow:
Hb 13.1g/dl
WCC 4.9109/l
PLT 210109/l
Na+ 139mmol/l
K+ 4.7mmol/l
Creatinine 120mol/l
CXR nocardiomegaly,noLVF
ECG fastatrialfibrillation,noQwaves
Whichofthefollowingisthemostappropriatetherapytochemicallycardioverthim?
A Adenosine
B Bisoprolol
C Digoxin
D Flecainide
E Verapamil
Explanation
Flecainide
IntheUKthedrugsmostcommonlyusedforcardioversionofatrialfibrillationareflecainideandamiodarone
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Successfulcardioversionisreportedinupto90%ofpatientsgivenivflecainide
Flecainideshouldbeavoidedinpatientswithapreviousischaemiccardiovascularhistory,astheCASTtrial
suggestedthatmortalitywasincreasedinpatientsgivenflecanidepostmyocardialinfarction
http://www.nejm.org/doi/full/10.1056/NEJM199103213241201
(http://www.nejm.org/doi/full/10.1056/NEJM199103213241201)
Othernotes
Digoxindoesnotcardiovert,andbisoprololandverapamilaremoreusuallyemployedtomaintainsinusrhythm
aftersuccessfulelectricalcardioversion
Aswehaveaveryclearhistoryofdurationofatrialfibrillationandnoevidenceofstructuralheartdisease,
successfulcardioversionislikelytobepossible
20911
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Question173of295
An18yearoldstudentwhohasneverbeenvaccinatedagainstmeaslespresentstohisGPwithsymptomssuggestiveof
thedisease.Heissenthomeandadvisedtorest,butlaterpresentstotheEmergencyDepartmentwithanteriorchestpain
thatisworseoninspirationandrelievedbysittingforward.Onexaminationthereappearstobearubonauscultation.
Whatdiagnosisfitsbestwiththisclinicalpicture?
A Myocardialischaemia
B Pericarditis
C Pneumothorax
D Secondarybacterialpneumonia
E Viralpleurisy
Explanation
TheanswerisPericarditis
Thepaindescribedisstronglysuggestiveofeitherpericarditisorpleuritis(AorB).Theinspiratorynatureandthe
factitisrelievedbysittingforwardpointsstronglytopericarditis(optionB).Thepresenceofarubvirtually
confirmsit.Thefactthatitfollowsarecentviralinfectionmakesitveryclassical.
Pericarditis
Pericarditispresentswithanteriorpleuriticchestpain,worseoninspirationandrelievedbysittingforward.
Associations
Itisassociatedwithapericardialfrictionrub,whichisbestheardwhenthepatientisuprightandleaningforward.
Theremaybeassociatedcardiactamponade,evidencedbytachycardia,lowbloodandpulsepressureanddistended
neckveins.
Origins
Theoriginofpericarditismaybe
infectious(viral,bacterialorfungal)
inflammatory(egrheumatoid,relatedtosystemiclupuserythematosus,sclerodermaorvasculitis)
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druginduced
myocardialinfarctionrelated
postradiotherapy
uraemic
neoplastic
relatedtosarcoid
orrelatedtoahostofothercauses.
Managementandprognosis
Forviralpericarditis,asinthiscase,limitationofactivityisadvisedwithadditionalpainreliefusingnonsteroidals
andopiatebasedagentssuchascodeinephosphate.
Inseverecases,oralprednisolonemaybeconsidered.
Prognosisvariesaccordingtotheunderlyingcause,butrecurrenceofpericarditisoccursin1015%ofpatientswith
pericarditiswithinthefirstyear.
Myocardialischaemia(OptionA)isincorrect.Patientswithmyocardialinfarctionaretypicallymoreunwellwithcentral
chestpainthatisabandorweightonthechest.Thereisradiationintotheneckand/orarm.Absenceofthesefeaturesrule
thisoutasadiagnosis.
Pneumothorax(OptionC)isincorrect.Patientswithpneumothorax(optionD)willhaveapleuriticpainbutaretypically
breathless.Theremaybeahistoryoftraumaorairwaysdisease.Absenceofthesefeaturesrulethisoutasadiagnosis.
Secondarybacterialpneumonia(OptionD)isincorrect.Bacterialpneumoniacanreadilycomplicateanyviralinfection,
buttheremaybefever,coughandpurulentsputum.Absenceofthesefeaturesrulethisoutasadiagnosis.
Viralpleurisy(OptionE)isincorrect.Reliefofthepainonsittingforwardmakespericarditismorelikely.
42007
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Question174of295
An82yearoldmanwasadmittedtotheEmergencyDepartmentfromalocalchurchservice.Hefaintedandanother
parishioner,whoisatrainedfirstaider,reportedthathewaspulselessforafewsecondsaftertheattack.Onexamination,
hisbloodpressurewas165/95mmHg(pasthistoryofhypertension),hehadnomurmursonauscultationofthechestand
carotidauscultationwasalsonormal.Outpatient7dayambulatorycardiacrhythmmonitoringwasarranged,whichisnow
reportedasnormal.
Whatdiagnosisfitsbestwiththispresentation?
A Carotidsinussyndrome
B Paroxysmalatrialfibrillation
C Simplesyncope
D Transientbradycardia
E Transientischaemicattack
Explanation
TheanswerisCarotidsinussyndrome
CarotidsinussyndromeIncidence
Theincidenceofcarotidsinussyndromeissaidtobearound10%intheadultpopulation.
Thisincidenceincreaseswithage,andmenareaffectedtwiceasoftenaswomen.
Presentationisrarebelowtheageof50years.
Theincidencealsoincreasesinpatientswithhypertension,butoftenadefinitivecausemaynotbeidentified.
Investigations
Predisposingfactorsmayinclude
headandnecktumours
necksurgery
significantlymphadenopathy
carotidbodytumours.
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Physicalexaminationinthiscasesuggeststhatthereisnosignificantcardiacpathology,andthe7dayHolter
monitorresultmakesarrhythmialesslikelyasacause.
Diagnosisandtreatment
SupinecarotidsinusmassagewithbloodpressureandECGmonitoringisthediagnosticprocedureacontinuous
ECGrecordingeitheronamonitororarhythmstripisessential.
Itshouldnotbeperformedinpatientswithahistoryofcerebrovasculardiseaseorcarotidbruits,andshouldonlybe
appliedtoonearteryatatime.
Theresponsemaybecardioinhibitorywithasystoleforatleast3s,orvasopressorwithadropofmorethan30
mmHg(inthepresenceofsymptoms)ormorethan50mmHgwithoutsymptoms.
Amixedpictureofacardioinhibitoryandvasopressorresponsemayoccur.
Pacemakerinsertionisrecommendedforpatientswithcardioinhibitorycarotidsinussyndrome.
Paroxysmalatrialfibrillation(AF)(OptionB)isincorrect.ParoxysmalAFisoftenattributedasacauseofcollapse,but
noneisnotedonthe7daymonitor.
Simplesyncope(OptionC)isincorrect.Simplesyncopeistypicallyassociatedwithaprodromeandthereshouldnotbea
prolongedperiodwithoutapulse.
Transientbradycardia(OptionD)isincorrect.Transientbradycardiaaloneshouldnotcauselossofconsciousnessunlessit
wasprofoundorassociatedwithlongpausesnoneisnotedonthe7daymonitor.
Transientischaemicattack(OptionE)isincorrect.Transientischaemicattacksshouldnotleadtoalossofconsciousness.
42015
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Question175of295
A60yearoldmansufferedananteriormyocardialinfarction.Hehadalltheriskfactorsforcoronaryarterydisease.
Whichoneofthefollowingnonpharmacologicalinterventionswillbemosthelpfulinreducinghisriskofafuture
ischaemicevent?
A Alcoholreduction
B Dietcontrol
C Regularexercise
D Stoppingsmoking
E Weightreduction
Explanation
Nonpharmacologicalinterventionsaftermyocardialinfarction
Alltheseinterventionsareeffectivebutstoppingsmokingisthesinglemosteffective,nonpharmacological
interventionthatwillhelptoreducetheriskofafutureevent
Therearetrialsshowingthatsmokingcessationisaseffectiveashavingacoronaryarterybypassgraft
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Question176of295
A65yearoldmanpresentstotheEmergencyDepartmentwithahistoryof40minutesofcentralcrushingchestpain
radiatingtohisleftarmsome8hrsearlier.HesufferedapreviousinferiorMIsome3yearsearlier,hashypertension
managedwithtwooralagents,andsmokes5cigarsperday.ExaminationrevealsaBPof105/60mmHg,pulseis75/min
andregular.Therearebilateralbasalcracklesonauscultationofthechest.
Investigations:
Hb 13.1g/dl
WCC 9.1x109/l
PLT 203x109/l
Na+ 137mmol/l
K+ 4.3mmol/l
Creatinine 132micromol/l
Glucose 9.3mmol/l
Troponin 1.5
ECG InferolateralTwaveinversion
Youreviewhimsome2hourslater,andhispainhasresolved,ashastheTwaveinversion.
Whichofthefollowingisthemostappropriatenextstep?
A Aspirin,Clopidogrel,Fondaparinux
B Aspirin,Prasugrel,LMWheparin
C Aspirin,Clopidogrel,Bivalirudin
D Aspirin,Clopidogrel,LMWheparin
E Aspirin,Prasugrel,Fondaparinux
Explanation
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ThecorrectanswerisAsprin,Clopidogrel,Fondaparinux
ThispatienthasanelevatedtroponinindicatinganNSTEMIandminorECGchanges.Thefactheisnowpainfreeand
hasbeenforthelast8hrs,meansthatangiographyinthenext24hrsisunlikelyandforthisreasonAspirin,Clopidogrel
andFondaparinuxistherecommendedregimen.Bivalirudinisconsideredinpatientslikelytoundergoangiography
within24hrs.PrasugrelisconsideredforSTEMIandwherepatientshaveahistoryofdiabetesmellitus.
https://www.nice.org.uk/guidance/cg94(https://www.nice.org.uk/guidance/cg94)
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Question177of295
Thepressurevolumecurveinapatientwithheartfailureisshiftedtotheright.
Whatisthemostimportantfeatureincardiovasculardynamicsresponsibleforthisrightshift?
A Increasedcontractilityofthechamber
B Increasedsympatheticactivity
C Concentrichypertrophyofthechamber
D Increasedcomplianceofthechamber
E Pressureoverloadinthechamber
Explanation
Rightshiftofthepressurevolumecurve
Shiftingofthepressurevolumecurvetotherightoccurswhenthereisvolumeoverload,asinaorticandmitral
regurgitation
Thereisdecreasedcontractilityandincreasedcompliance
Theventricledilatestoaccommodatetheincreasedvolume
Hypertrophyofthecardiacmuscledoesnotoccur
Increasedsympatheticactivity,catecholamineadministrationorexercisewouldshiftthepressurevolumecurveto
theleft
Thefigurebelowshowstheeffectsofacuteleftventricularfailure(lossofinotropy)onleftventricularpressurevolume
loop.Heartrateunchanged
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Question178of295
A72yearoldmanwhovisitedhisGPsufferingfromaninfection2daysearlierisadmittedtotheEmergencyDepartment
aftersufferingacollapseatthesupermarket.Hiswifetellsyouthathesufferedfromamyocardialinfarctionsome6years
ago,buthasotherwisebeenrelativelywell,takingaspirin,ramiprilandatorvastatinasregularmedications.Shedoesnt
knowthetypeofantibioticshehasbeentaking.OnexaminationhisBPis120/71mmHgandheisdrowsy.Hispulseis70
bpmandregular.Clinicalresultsaregiveninthetablebelow:
Hb 13.1g/dl
WCC 5.1109/l
PLT 232109/l
Na+ 140mmol/l
K+ 4.2mmol/l
Creatinine 123mol/l
Shortrunsoftorsadesseenonthemonitor
Whichoneofthefollowingisthemostlikelycausativeantibiotic?
A Oxytetracycline
B Metronidazole
C Coamoxiclav
D Cefalexin
E Clarithromycin
Explanation
Antibiotics
Bothmacrolidessuchaserythromycin,andclarithromycin,andquinolonessuchasciprofloxacinandolfloxacin
mayleadtoQTprolongation,whichpredisposestothedevelopmentoftorsadesdespointesVT
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TheproblemmaybeexacerbatedbycoadministrationwithCYPP450inhibitorssuchasketoconazole
Initialmanagementinvolveswithdrawalofthepotentialoffendingagentandelectrolyteassaytoexcludepotential
exacerbatingfactorssuchashypomagnesaemia
20914
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Question179of295
A61yearoldmanisreferredtothefallsclinicaftersufferingasecondsyncopalepisodeinthepastfewmonths.He
apparentlycollapsedinthelocalTescostorewithverylittlewarning.Pasthistoryofnoteincludeserectiledysfunctionfor
whichhewasprescribedaPDE5inhibitor,andaccordingtohiswifehehasbecomealittleunsteadyonhisfeetand
vagueoverthepastfewmonths.OnexaminationhisBPis122/60mmHg,fallingto90/50mmHgonstanding.Thereis
posturalinstabilitycoupledwithanataxicgaitwhenyougethimtowalkaccrosstheconsultingroom.Younotice
nystagmusonexaminationofhiscranialnerves.
Whichofthefollowingisthemostappropriateinitialtherapyforhisbloodpressure?
A Fludrocortisone
B Midodrine
C Supportstockings
D StopthePDE5inhibitor
E Increasedsaltinthediet
Explanation
TheanswerisSupportstockings
Thismanhasfeaturesofmultisystematrophy,andautonomicdysfunctionisthemostlikelycauseofhispostural
hypotension.Nondruginterventionsincludeuseofsupportstockingswhichmaysignificantlyreducetheriskofsyncopal
episodes.Thiscanbefollowedbylowdosefludrocortisoneandmidodrineinresistantcases.Itisunlikelythatstopping
thePDE5inhibitorwillhelp,andincreasingsaltinhisdietwillonlyhaveaminoreffectversustheotheroptions.
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Question180of295
A40yearoldsalesmanpresentswithfrequentflushingofhisfaceandneck,abdominalpainandwaterydiarrhoea,
fatigue,breathlessness,anorexiaandnausea.Onexamination,thereisjugularvenousdistensionwithprominentvwaves,
hepatomegalyanddependentoedema.Onauscultation,ablowingpansystolicmurmurisheardoninspirationatthelower
leftsternaledge.Whatisthemostlikelycardiacabnormalityinthiscase?
A Mitralregurgitation
B Tricuspidincompetence
C Tricuspidstenosis
D Pulmonarystenosis
E Prolapsingmitralvalve
Explanation
Auscultationincardiacabnormalities
Tricuspidincompetence
Thispatientmostprobablyhascarcinoidsyndrome,whichcanoccurin5%ofpatientswithcarcinoidtumours
whentherearelivermetastases
Cardiacabnormalitiesarefoundin50%ofpatients,andconsistofpulmonarystenosisortricuspidincompetence
Theauscultatoryfindingsinthiscasearesuggestiveoftricuspidincompetence.
Pulmonarystenosis
Inpulmonarystenosis,thecharacteristicauscultatoryfindingisaharshmidsystolicejectionmurmurbestheard
oninspirationtotheleftofthesternuminthesecondintercostalspace
Arightventricularfourthsoundandaprominentjugularvenousawavearebothpresentwhenthestenosisis
moderatelysevere
Arumblingmiddiastolicmurmurischaracteristicoftricuspidstenosisalongwithaprominentjugularvenousa
wave
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Mitralregurgitation
Mitralregurgitationdoesnotusuallyoccurduetocarcinoidsyndrome
Inmitralregurgitation,apansystolicmurmurisheardloudestattheapexandradiatingwidelyovertheprecordium
andintotheaxilla
Aprominentthirdheartsoundmaybepresent
Mitralvalveprolapse
Prolapsing(floppy)mitralvalveiscommonlyseeninyoungwomenandhasafamilialincidence
Itmaybeassociatedwithrheumaticorischaemicheartdisease,Marfansyndromeandthyrotoxicosis
Themostcommonsignisamidsystolicclickfollowedbyalatesystolicmurmurduetosomeregurgitation
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Question181of295
A65yearoldwomanwithsevereheartfailurepresentswithincreasingshortnessofbreath.Hercurrentpharmacological
treatmentconsistsofanangiotensinconvertingenzyme(ACE)inhibitor,loopdiureticandblocker.Thereisonlymild
ankleswellingandbilateralbasalcracklesonauscultationofthechest.HerBPis142/82mmHg.
Whichoneofthefollowingisthemostappropriatemanagement?
A Adddigoxin
B Addspironolactone
C Stopblocker
D StopACEinhibitor
E Addsimvastatin
Explanation
Treatmentofheartfailure
Thepositiveinotropiceffectsofcardiacglycosidescanbeusefulinreducingsymptoms(mainlybreathlessness)in
patientsalreadytakingdiureticsandangiotensinconvertingenzyme(ACE)inhibitors
However,theyhavenoeffectonmortalityandmustbeusedwithcautioninpatientssuchasthiswhoareproneto
disturbancesofpotassium
Lowdosespironolactonehasbeenshowntohavepositiveeffectsoncardiovascularmortalityinpatientswithend
stageheartfailure
Largeoutcomestudieswithcarvedilolandbisprololhavealsoshownamortalitybenefitinheartfailure
Itwaspreviouslyrecommendedthatbetablockersbetemporarilydiscontinuedinfluidoverload,althoughone
RCTsuggestedthatdiscontinuingthemhadnopositiveimpactonoutcomes.Hencediscontinuingthemisnow
discouraged.
http://www.nejm.org/doi/full/10.1056/NEJM199909023411001
(http://www.nejm.org/doi/full/10.1056/NEJM199909023411001)
5603
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Question182of295
Whichoneofthefollowingpharmacologicalagentsismostlikelytobenefitapatientwithanginaduetocardiacsyndrome
X?
A Aspirin
B Bisoprolol
C Diazepam
D Atenolol
E Isosorbidemononitrate
Explanation
SyndromeX
NitratesareofteneffectiveinpatientswithsyndromeX,asaretherangeofcalciumantagonistsincludingdihydropyridine
andnondihydropyridineagents.
CardiacsyndromeX
CardiacsyndromeXconsistsof
anginalikechestpainduringexertion
characteristicECGchangesduringexercisetesting
normalcoronaryarteriesoncardiaccatheterisation
noinduciblecoronaryarteryspasmduringcatheterisation
MetabolicsyndromeX
ItshouldnotbeconfusedwiththemetabolicsyndromeX,whichcomprises
centralobesity
glucoseintolerance
dyslipidaemia
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highbloodpressure
Thedyslipidaemiainthiscaseisprimarilyhightriglyceridesandlowhighdensitylipoproteincholesterol
Peoplewithmetabolicsyndromeareatincreasedriskofcoronaryarterydisease
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Question183of295
A46yearoldAsianmanwithapasthistoryofcoronaryarterybypassgraftingpresentswithbreathlessness.Thejugular
venouspressure(JVP)showsprominentxandydescents.
Whatisthemostlikelycause?
A Constrictivepericarditis
B Dilatedcardiomyopathy
C Pericardialeffusion
D Restrictivecardiomyopathy
E Severemitralregurgitation
Explanation
Constrictivepericarditis
Aprominentxdescentinthejugularvenouspressure(JVP)mayoccurinconstrictivepericarditisorpericardial
effusion
Theydescentislostintamponadebutprominentinconstrictivepericarditis
Constrictivepericarditiswasclassicallycausedbytuberculosis,buttodayismorecommonlyassociatedwith
cardiacsurgery,renalfailureorfollowinginfectivepericarditis.Thehistoryofpreviouscoronaryarterybypass
graftingiswhatincreasesthelikelihoodofconstrictivepericarditisbeingtheunderlyingdiagnosis
Restrictivecardiomyopathymayproduceclinicalfeaturessimilartoconstriction,butislesscommon,itmaybe
associatedwithamyloidosisorsarcoidosisforexample,neitherofwhicharesuggestedbythescenariohere
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Question184of295
A45yearoldasthmaticpatientpresentswithpalpitations.Heisonnoothermedicationapartfromhisasthmatherapies.
AnECGshowssupraventriculartachycardia,withnarrowQRScomplexes.Carotidsinusmassageisnotsuccessful.His
bloodpressureismaintainedat128/72mmHg.
Whatwouldyoudonext?
A Administerintravenousadenosine
B Administerintravenousverapamil
C Administerintravenousdigoxin
D Administerintravenoussotalol
E DCcardioversion
Explanation
TheanswerisAdministerintravenousverapamil
Verapamilisthedrugofchoiceinthiscaseas,althoughadenosine(OptionA)istypicallythefirstline
pharmacologicaltherapyforterminatingparoxysmalsupraventriculartachycardia,itcancausebronchospasmandis
thuscontraindicatedinpatientswithasthma.Sotalol(OptionD)shouldbeavoidedforthesamereason.
Contraindicationsofverapamil
VerapamilshouldnotbeusedfortachyarrhythmiaswheretheQRScomplexiswide
ItisalsoavoidedinpatientswiththeWolffParkinsonWhitesyndromethereasonbeingselectiveAVNblockade
couldencouragerapidconductionoftheatrialarrhythmiatotheventricle(thisisprincipallyaproblemwithpre
excitedAF(AFwithWPW)
Administerintravenousadenosine(OptionA)isincorrect.Adenosineiscontraindicatedinpatientswithasthmaasitcan
causebronchospasm.
Administerintravenousdigoxin(OptionC)isincorrect.Digoxinisnotusefulforcardioversionandhaslittlerolein
managementofyoungpatientsorthosewithSVT.
Administerintravenoussotalol(OptionD)isincorrect.Sotaloliscontraindicatedinpatientswithasthmaasitcancause
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bronchospasm.
DCcardioversion(OptionE)isincorrect.AlthoughsynchronizedDCcardioversionwouldachievecardioversion,asthe
patientdoesnothaveanyadversehaemodynamicfeatures(thatis,hisbloodpressureismaintained)thisoptionhasa
higherriskthanpharmacologicalcardioversion.
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Question185of295
Anobese(BMI=30)53yearoldwomanpresentswithamyocardialinfarction.HermotherhastypeIIdiabetes.Her
cholesterolis6.1mmol/l.
Whichoneofthefollowinginterventionsistheleastlikelytoprolonghersurvival?
A ACEinhibitor
B Aspirin
C Betablocker
D Isosorbidemononitrate
E Statins
Explanation
TheanswerisIsosorbidemononitrate
Thequestionwordingiskeyhere.Isosorbidemononitrateisusedtoreduceanginalsymptomsbuthasnodatato
suggestitreducescardiovascularevents.Therefore,itistheleastlikelytoprolongsurvivalandisthecorrectanswer
forthisquestion.
Secondarypreventionaftermyocardialinfarction
Afterapatienthashadamyocardialinfarction(MI),itisimperativetoconsiderallmodifiableriskfactorsto
lowertheriskoffurthervascularevents.
Nonpharmacologicalinterventions
Themostimportantinterventionistostopsmokingafterjust1yearthereisasignificantdropintheriskof
MI.
Weightlossinanobeseindividualwillreducecomorbiditybuthasnotbeenshowntoprolongsurvival.
Itwouldbeethicallyimpossibletoarrangerandomisedtrialsofsmokingcessationorweightloss,sosuch
interventionshavetorelyonepidemiologicalevidencetojudgetheoutcome.
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Pharmacologicalinterventions
Intheotherinterventionstrialevidencehasgivenanumberofpatientsneededtotreatinordertopreventone
fatality(NNT),andthisisonewayofjudgingwhichinterventionhasthemostlikelihoodofprolonging
survival.
ForblockerstheNNTis143(ISIS1study).
ForaspirintheNNTis42(ISIS2study).
Forangiotensinconvertingenzyme(ACE)inhibitorstheNNTis22(SOLVD)andforstatinstheNNTis33
(CARE).
Inpractice,anumberoftheseinterventionswouldbecommencedtogether.
ACEinhibitor(OptionA)isincorrect.Asdescribedbetablockerwouldnotoffertheleastimpactonhersurvivalhere.
Aspirin(OptionB)isincorrect.Asdescribedaspirinwouldnotoffertheleastimpactonhersurvivalhere.
Betablocker(OptionC)isincorrect.Asdescribedbetablockerwouldnotoffertheleastimpactonhersurvivalhere.
Statins(OptionE)isincorrect.Asdescribedastatinwouldnotoffertheleastimpactonhersurvivalhere.
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Question186of295
A52yearoldwomanpresentstotheclinicwithshortnessofbreathandangina.Shehasahistoryofhypertensionand
type2diabetesforwhichshetakesmetforminandBDMixedInsulin.OnexaminationherBPis155/92mmHg.You
noticereversedsplittingofthesecondheartsoundandbibasalcracklesonauscultationofthechestconsistentwithcardiac
failure.WhichoneofthefollowingisthemostlikelyfindingonECG?
A Rightbundlebranchblock
B QTprolongation
C Pmitrale
D Ppulmonale
E Leftbundlebranchblock
Explanation
Reversedsplittingofthesecondheartsoundoccurswhenclosureofthepulmonaryvalveoccursbeforetheaortic
valve
Conditionsassociatedwithreversedsplittingofthesecondheartsoundincludeleftbundlebranchblock,
hypertrophicobstructivecardiomyopathyandaorticstenosis
Fixedsplittingofthesecondheartsoundisassociatedwithanatrialseptalorventricularseptaldefect
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Question187of295
A24yearoldmanfromatravellingfamilywhohasshunnedregularmedicalfollowupcomestothecliniccomplaining
ofshortnessofbreathandchestpain.OnexaminationhisBPis145/82mmHg,heiscyanosedandshortofbreathatrest.
Youreviewhiscatheterisationresults,giveninthetablebelow:
PressureRV 110/0mmHg
PressureLV 90/0mmHg
LVoxygensaturation 88%
Giventheprobableclinicaldiagnosis,whichoneofthefollowingisthemostlikelyfindingonclinicalexamination?
A Adiastolicmurmur
B Persistenthypoxiadespitemaximaloxygentherapy
C Tappingapexbeat
D BroadPwavesonECG
E DecreasedpulmonaryvasculatureonCXR
Explanation
Persistenthypoxia
Thismanhasarighttoleftshunt,withrightventricularpressuregreaterthantheleft
Thereisclearmixingofdeoxygenatedandoxygenatedbloodwithintheleftventricle,asevidencedbytheleft
ventricularoxygensaturationof88%
Themostlikelydiagnosisisalongstandingventricularseptaldefect(VSD)
Thetypicalmurmurseenisaholosystolicmurmur,andtheapexbeatisusuallydisplaced
PwavesaretallontheECG,asigntypicalofthatseenwithrightatrialoverloadduetopulmonaryhypertension
Becauseofpulmonaryhypertension,increasedpulmonaryvasculaturemarkingsarenormallyseenonthechestX
ray(CXR)
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Question188of295
A65yearoldmanwithanginapectorisundergoesserumlipidtesting.Whichoneofthefollowingabnormalitiesismost
likelytobefound?
A Increasedtriglyceridelevels
B Increasedlowdensitylipoproteincholesterollevels
C Increasedhighdensitylipoproteincholesterollevels
D Increasedchylomicrons
E Increasedintermediatedensitylipoproteincholesterollevels
Explanation
Serumlipidtesting
Lowdensitylipoprotein
Lowdensitylipiprotein(LDL)particlesarethemaincarriersofcholesterol
Theseparticlescandepositlipidintothewallsoftheperipheralvasculature
ThereisastrongassociationbetweenbothtotalandLDLcholesterolconcentrationandcoronaryheartrisk
Thereisarelativelyweakindependentlinkbetweenraisedconcentrationsof(triglyceriderich)VLDL(verylow
densitylipoprotein)particlesandcardiovascularrisk
Triglycerides
Veryhighlyraisedtriglyceridelevels(>6mmol/litre)causeagreatlyincreasedriskofacutepancreatitisand
retinalveinthrombosis
Highdensitylipoprotein
Higherhighdensitylipoprotein(HDL)concentrationsprotectagainstcardiovasculardisease
HDLalsohaseffectsonthefunctionofplateletsandofthehaemostaticcascade
Thesepropertiesmayfavourablyinfluencethrombogenesis
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Chylomicrons
Excesschylomicronsdonotconferanexcesscardiovascularriskbutdoraisethetotalplasmatriglyceride
concentration
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Question189of295
A25yearoldprimigravidawhois26weekspregnant,presentstotheEmergencyDepartmentwithsymptomsof
headache,flashinglightsandvomiting.Herbloodpressurewasrecordedat140/100mmHgandherantenataldiary
showedconsistentsystolicreadingsof110120mmHgandconsistentdiastolicreadingsoflessthan80mmHg.Shehasa
historyofmildasthmabutwasotherwiseingoodhealthpriortopregnancy,andthereisnofamilyhistoryofnote.
Whichoneofthefollowingwouldbethepreferredoption?
A Valsartan
B Labetalol
C Methyldopa
D Nifedipine
E Ramipril
Explanation
TheanswerisMethyldopa
Preeclampsiaisdiagnosedwhenapregnantwomanhasnewhypertensiontogetherwithconfirmedproteinuria(>
300mgona24hourcollection).Thebloodpressurecriteriawilldependonwhetherthewomanwasnormotensive
previously.TypicallyaBP140mmHgsystolicor90mmHgdiastolicontwoseparatereadingstakenatleast4
6hoursapartafter20weeksgestationisusedinanindividualwithpreviouslynormalbloodpressure.
Inthosewomenwithessentialhypertensionbeginningbefore20weeksgestationalage,thediagnosticcriteriaare:an
increaseinsystolicbloodpressure(SBP)of30mmHgoranincreaseindiastolicbloodpressure(DBP)of15
mmHg.
Iftheabovecritieriaarepresent,withoutproteinuria,thenthetermgestationalhypertension(orhypertensionin
pregnancy)isused.
Magnesiumsulfateisusedforseizurepreventionandtreatment,andaspirinmaybeindicatedinsomecases.
Valsartan(OptionA)isincorrect.Valsartan(anangiotensinreceptorblocker)iscontraindicated.
Labetalol(OptionB)isincorrect.NICEguidancerecommendslabetalolasfirstlinetherapyforgestationalhypertension,
butinthiscasemethyldopawouldbethepreferredchoiceduetoherhistoryofasthma.Inthiscasebetablockerswould
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becontraindicated.
Nifedipine(OptionD)isincorrect.Anyoflabetalol,methyldopaandnifedipinecanbeusedinpreeclampsia,although
thefirsttwoarepreferred,largelybasedonevidencefromcaseseries.
Ramipril(OptionE)isincorrect.ACEinhibitorsarecontraindicatedinpregnancybecausetheycancausefetalharm,
oligohydramnios,renalfailureandintrauterinedeath.
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Question190of295
A68yearoldwomanrecentlydiagnosedwithmultiplemyelomapresentstoherGPwithprogressivelyincreasing
breathlessness,exerciseintoleranceandankleswelling.Onexamination,thereisbilateralpittinglegoedematoherthighs,
ascitesandraisedJVP.Theapicalimpulseisimpalpable.AnECGshowsdiffuselydiminishedvoltage.ChestXrayis
normalandtheechocardiogramshowssmall,thickventriclesanddilatedatriawithathickenedinteratrialseptum.The
ventricularmyocardiumhasagranularsparklingtextureonecho,andminimalfluidinthepericardialspaceisnoted.
Whatisthemostlikelydiagnosisleadingtosymptomsofcardiacfailure?
A Chronicpericardialeffusionwithtamponade
B Chronicpericardialeffusionwithouttamponade
C Constrictivepericarditis
D Restrictivecardiomyopathy
E Congestiveheartfailure
Explanation
TheanswerisRestrictivecardiomyopathy
Thekeyfeatureinthisscenarioisthatthepatienthasmultiplemyelomawhichisknowntoproduceexcessive
immunoglobulinlightchains,whichcancauseasecondarycardiacamyloidthisisatypeofrestrictive
cardiomyopathy.
Restrictivecardiomyopathy
Aetiology
Restrictivecardiomyopathycandevelopsecondarytoamyloidosisassociatedwithanimmunocytedyscrasia.
Examinationandinvestigationfindings
PhysicalexaminationrevealsrightheartfailurewitharaisedJVP,characteristicallyshowingaprominentdeepY
descent
Theheartsizeisoftennormal
Thephysicalfindingsareverysimilarinconstrictivepericarditis(CCP),buttheapexisfrequentlynonpalpable
duetothethickpericardium
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ThechestXraymayshowpericardialcalcificationsinpatientswithconstrictivepericarditis
Pericardialeffusioniscommon,butrarelycausestamponade
ECG
ThemostcharacteristicECGfindingofrestrictivecardiomyopathyisdiffuselydiminishedvoltages
Echocardiographytypicallyshowssmall,thickventriclesandathickinteratrialseptumduetoamyloiddeposits,
whichhaveagranularsparklingappearance
Adverseeffects
Cardiacinvolvementisthemostcommoncauseofdeathinpatientswithamyloidosisassociatedwithan
immunocytedyscrasiatypicallyasrestrictivecardiomyopathy
Chronicpericardialeffusionwithtamponade(OptionA)isincorrect.Inchronicpericardialeffusionswithtamponade,the
patientmayexhibitelectricalalternansontheECG(QRScomplexesvaryinsizebetweenbeatsduetothemovementof
theheartintheeffusion).Echocardiographicfindingswouldexhibitcollapseoftherightatriumfirst,followedbycollapse
oftherightventricle.Whenthisoccurs,haemodynamiccollapseoccursandpatientsaretypicallyperiarrest.Slowly
accumulatingeffusionsfrommorechronicinflammatoryconditionscantakealongtimebeforetamponadeoccursasthe
pericardiumenlargestoaccommodatetheslowfluidaccumulation.Inthissituation,thesizeoftheeffusioncanbelarge
beforetamponadeoccurs.Inacutetamponadesituationssuchasafteracutetraumatotheheartorcoronaryruptureduring
PCI,tamponadeoccurswithasmallamountoffluid.Nopericardialeffusioncanbeseenonechowhichmakesthisoption
unlikely.
Chronicpericardialeffusionwithouttamponade(OptionB)isincorrect.Nopericardialeffusionvisibleonechomakesthis
optionunlikely.
Constrictivepericarditis(OptionC)isincorrect.Constrictivepericarditistypicallyoccursafteraninflammatorycondition
causesrecurrentpericarditiswithsubsequentscarringofthepericardium.Thisthenlimitsventricularfillingandcausesa
typeofdiastolicheartfailure.However,theventricularappearanceistypicallynormalandhencethiscannotbeanswer.
Congestiveheartfailure(OptionE)isincorrect.Incongestiveheartfailuretheventriclesaretypicallyimpairedand
dilatedthechestXrayfindingswillshowsomepulmonaryoedema.Thisoptionthereforecannotbecorrect.
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Question191of295
A67yearoldwomanpresentstotheclinicwithprogressivelyworseningshortnessofbreath.Frombeingabletorideher
bicycletotheshops,sheisnowunableeventowalktotheendofthestreetwithoutgettingshortofbreath.Overthepast
fewweeksshehasalsonoticedanirregularheartbeat.Shehasnopastmedicalhistoryofnote,althoughherGPrecently
gaveheraSalbutamolinhaler,Ramipril5mg,ISMN60mgSRandFurosemide40mgdailywhichhadnosignificant
impactonhershortnessofbreath.OnexaminationherBPis110/72mmHg,pulseis84withatrialfibrillation,andshehas
amalarflush.Therearebibasalcracklesonauscultationofthechest.
Investigations
Hb 12.8g/dl
WCC 8.3x109/l
PLT 181x109/l
Na+ 137mmol/l
K+ 4.3mmol/l
Glucose 5.3mmol/l
evidenceofseveremitralstenosis,moderatemitralregurgitation,leftatrialenlargement,ejection
Echocardiography
fraction41%
CXR Bilateralupperlobediversion
Whichofthefollowingisthemostappropriateintervention?
A IncreasedFurosemide
B IncreasedRamipril
C Percutaneouscommissuralmitralvalvotomy(PMC)
D Surgicalvalvereplacement
E Trialofbetablocker
Explanation
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TheanswerisSurgicalvalvereplacement
Thispatienthassymptomaticcardiacfailureasaresultofseveremitralstenosiscomplicatedbyatrialfibrillation.The
interventionofchoiceisPMCexceptincasessuchasthisonewhenthereismorethanmildmitralregurgitationinthis
situationsurgicalvalvereplacementisthebestoption.GiventhatthesystolicBPisonly110mmHg,thereislimitedscope
tofurtherincreasemedicaltherapy.Sheshouldbeanticoagulatedtoreducetheriskofstrokerelatedtotheatrial
fibrillation.
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Question192of295
A75yearoldmanisreferredtotheclinicforinvestigationofanejectionsystolicmurmursuspiciousofaorticstenosis.
HehasahistoryofhypertensionthatiscurrentlymanagedwithacombinationofLisinopril,AmlodipineandIndapamide.
OnexaminationhisBPis148/105mmHgpulseis80/minandregular.Thereisanejectionsystolicmurmurloudestinthe
aorticarea.Younotemildpittingoedemaofbothankles.
Whichofthefollowingismostimportantwithregardstoassessingneedforsurgicalintervention?
A Elevatedserumcreatinine
B Gradientacrossthevalve
C Loudnessofthemurmur
D LoudnessoftheA2heartsound
E Syncopalepisodes
Explanation
TheanswerisSyncopalepisodes
Gradientacrossthevalvewashistoricallythemaindriverforprogressiontosurgery,butitisnowrecognisedthatsudden
deathoccursmuchmorecommonlyinpatientswithaorticstenosiswhohavesymptomsversusthosewhodonot.In
patientswhohaveaorticstenosiswithoutsymptoms,mortalityisapproximately1%peryear.Thiscontrastswith
mortality,whichapproaches25%peryearinpatientswithsymptomsofheartfailureorsyncopalepisodes.Inaortic
stenosis,A2becomesquieterwithincreasingseverityofvalvedisease.Themurmuritselfmaybecomequieterinpatients
withseverevalvediseasebecauseofcoexistentleftventricularpumpfailure.Inpatientswithsignificantlysymptomatic
AS,useofACEinhibitorsshouldbereviewedbyacardiologist.
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Question193of295
A50yearoldmaleisbroughttotheEmergencyDepartmentwithacuteonsetcentralchestpainthatstarted1hoursago.
HisECGtakenonarrivalshowedSTelevationsof4mminleadsII,III,aVFandV4V6withhyperacuteTwaves.His
pulsewas60bpmandhisBPwas146/60.TheSaO2was92%.HewasgivenO2bymaskandtwolargeintravenous
cannulaswereinserted.
Whichoneofthefollowingbloodtestswouldbemostusefultowaitforpriortocommencingdefinitivetreatment?
A Myoglobin
B TroponinI
C CKMB
D Lactatedehydrogenase(LDH)
E None
Explanation
TheanswerisNone
ThisquestionrequiresrecognitionthatthereareclearsignsofacuteSTelevationmyocardialinfarctionandthere
shouldbenodelaytoawaitbloodtests.HehastypicalchestpainwithsignificantSTelevationinmultipleleads.He
shouldbetreatedimmediatelywithreperfusionbyPPCIifpossible.ThereforeonlyansweroptionEiscorrect.
Acutemyocardialinfarction
Diagnosiscriteria
TheWHOcriteriaforthediagnosisofacutemyocardialinfarction(MI)requiresthepresenceofatleasttwoof
threeelements
historyofischaemictypechestdiscomfort
evolutionaryECGchanges
riseandfallinserumcardiacmarkers
Inthispatient,adiagnosisofMIcanbemadeonthebasisofthefirsttwocriteria
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NofurthertimeshouldbewastedbeforereperfusinganSTelevationMI(STEMI),generallybypercutaneous
transluminalcoronaryintervention(PTCI)
Cardiacmarkers
InthecaseofnonSTelevationMI(NSTEMI),theserumcardiacmarkersbecomeelevated
Thecommonlyusedcardiacmarkersarecreatininekinase(CK),creatininekinasemyocardialtype(CKMB)and
troponin(Trop)I/TropT
Theearliesttimeatwhichthevariouscardiacmarkersriseareshowninthetable
Myoglobin(OptionA)isincorrect.Basedontheclinicalpresentationthereshouldbenodelaytoawaitbloodtests.
TroponinI(OptionB)isincorrect.Basedontheclinicalpresentationthereshouldbenodelaytoawaitbloodtests.
CKMB(OptionC)isincorrect.Basedontheclinicalpresentationthereshouldbenodelaytoawaitbloodtests.
Lactatedehydrogenase(LDH)(OptionD)isincorrect.Basedontheclinicalpresentationthereshouldbenodelaytoawait
bloodtests.
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Question194of295
Youreviewa55yearoldmanwithparoxysmalatrialfibrillationwhohastwoepisodesayear.Hehasastructurally
normalheartandisawareofwhenhisAFbegins.Hewouldpreferapillinthepocketapproach.
Whatstatementbestdescribesapillinthepocketapproach?
A Amiodaroneistheidealagentbecauseofitsshorthalflife
B Episodesofsilentatrialfibrillationcanbeoccurring
C Flecainideiscontraindicated
D Itisonlyappropriateinpatientsafterablationhasbeendeclined.
E Oralanticoagulationisnotnecessaryinpatientswiththis
Explanation
TheanswerisEpisodesofsilentatrialfibrillationcanbeoccurring
Withlongmonitoringdevices,itisnowknownthat,eveninpatientswithdiscrete,clearlysymptomaticepisodesof
atrialfibrillation,therecanbeothersilentepisodesofwhichthepatientisunaware.
Amiodaroneistheidealagentbecauseofitsshorthalflife(OptionA)isincorrect.Amiodaronehasalonghalflifeand
takesalongtimetoachieveadequateloading.Oncediscontinued,itpersistsinthebodyforalongtime.Assuch,oral
amiodaroneisnotsuitableforthepillinthepocketapproach.
Flecainideiscontraindicated(OptionC)isincorrect.Flecainideisanidealagentforpillinthepocket,andisonly
contraindicatedinthosewithimpairedventriclesaftermyocardialinfarction.
Itisonlyappropriateinpatientsafterablationhasbeendeclined(OptionD)isincorrect.Thepillinthepocketapproachis
suitableforyoungpatientswithdiscretesymptomaticepisodeswithclearsymptomswhichcanbetreatedwith
medications.Thisavoidshavingtotakeregularmedications,buttheremaybesilentepisodesofAFandtheriskofstroke
remains,requiringanticoagulationaccordingtotheCHADS2VAScscore.
Oralanticoagulationisnotnecessaryinpatientswiththisapproach(OptionE)isincorrect.Anticoagulationdecisions
shouldalwaysbebasedupontheCHADS2VAScscoreandisappropriateinallpatientswithAF,whetherparoxysmal,
persistent,orpermanent.
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Question195of295
Cardiaccatheterisationisperformedona25yearoldmanwithasystolicmurmurbutnosymptoms.ECGandchestXray
arenormal.Thefindingsareasfollows(pressuresmmHg):aorta,125/70leftventricle,120/12rightatrium,mean8
rightventricle,40/8pulmonaryartery,44/14pulmonarycapillarywedge,mean13.Saturations(%):aorta,97superior
venacava,70rightatrium,70rightventricle,82pulmonaryartery,85.
Whatisthemostlikelycardiacdiagnosis?
A Atrialseptaldefect(ASD)primum
B ASDsecundum
C Mitralstenosis
D Primarypulmonaryhypertension
E Ventricularseptaldefect
Explanation
TheanswerisVentricularseptaldefect
Ventricularseptaldefect
Catheterdata:youshouldbefamiliarwiththeintracardiacpressuresandsaturations.
Theaccompanyingfigureshowstypicalsaturations.Thetableshowspressures.
Inthiscase,aortic,leftventricularandrightatrialpressuresarenormal.Therightventricularpressureiselevated
andthereareelevatedpulmonaryarterypressures.Ameanpulmonaryarterypressureofover25mmHgisconsistent
withpulmonaryhypertension.Thewedgepressure,whichisanindirectmeasureoftheleftatriumpressure,isalso
normal.Notethatwedgepressuresarecalculatedbyinflatingaballooninthesmallpulmonaryarteriesuntilthe
vesselisnearlyfullyoccluded:thepressurewaveformthenreflectstheleftatriumpressure,whichcouldnot
otherwisebemeasuredwithoutpuncturingtheatrialseptum.
Normalpressurerange(mmHg)
Site
(systolic/diastolic)
Centralvenouspressure 38
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Rightventricularpressure 1530/38
Pulmonaryarterypressure 1525/412
Pulmonarycapillarywedgepressure(equivalenttoleftatrial
215
pressure)
Leftventricularpressure 100140/312
Therefore,thereissignificantlyelevatedrightventricularpressure.Thereisalsoaclearstepupinsaturationsinthe
rightventricularlevel.Thissuggeststhereisaproblemintheventricularseptumsuchasaventricularseptaldefect
(VSD)withlefttorightshuntingieleftsidedpressuresandbloodarebeingtransmittedtotheright.
VSDs
VSDisthecommonestformofcongenitalheartdisease
InadultsasmalldefectmaypresentasanasymptomaticmurmurorintheextremeasEisenmengersyndrome,
wherereversalofalefttorightshunthasoccurredasaconsequenceofadvancedpulmonaryhypertension
VSDisassociatedwithanincreasedriskofendocarditis,althoughthe2006NICEguidelinesdonotsaythatroutine
antibioticprophylaxisisrecommended.Theseguidelinesarecurrentlyunderreviewandmaychange
Managementdependsupontheactualsizeoftheshunt:ifthereisnosignificantshuntingthenconservative
managementmaybeappropriate.Themajorityareclosedsurgicallyiftheyaresignificant
ASDprimum(OptionA)isincorrect.Asdescribedthisisnotthemostlikelydiagnosis.
ASDsecundum(OptionB)isincorrect.Asdescribedthisisnotthemostlikelydiagnosis.
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Mitralstenosis(OptionC)isincorrect.Asdescribedthisisnotthemostlikelydiagnosis.
Primarypulmonaryhypertension(OptionD)isincorrect.Asdescribedthisisnotthemostlikelydiagnosis.
41932
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Question196of295
Whatdoesaprominentleftprecordiumina16yearoldyoungmanwithanejectionmurmurinthesecondleftintercostal
spaceindicate?
A ASDwithaorticregurgitation
B ASDwithaorticstenosis
C ASDwithmitralstenosis
D ASDwithpulmonaryhypertension
E UncomplicatedASD
Explanation
Atrialseptaldefect
Aprominentleftprecordiumsuggeststhattherightventriclewasdilatedduringchildhood
Italsosuggeststhatitwasworkingagainstahighpressure
Ostiumsecondumatrialseptaldefect(ASD)incombinationwithrheumaticmitralstenosis(Lutembacher
syndrome)cancausethesamepictureinadvancedcaseswhenthereispulmonaryhypertension,butoptionDisa
betterchoicethanC
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Question197of295
A57yearoldfemaleisadmittedwithGramnegativesepticaemia.Sheisgivenintravenousantibioticsandnormalsaline.
Twodayslatershebecomesanxious,tachypnoeicandshortofbreath.AnemergencychestXraydemonstratesdiffuse,
bilateralinterstitialandalveolarinfiltrates.Herpastmedicalhistoryrevealedhypertensionandthatshehasbeenon
regularantihypertensivetreatmentfor7years.Shehasneverhadanyevidenceofcongestiveheartfailure.
Inthiscase,adultrespiratorydistresssyndromecanbedistinguishedfromcardiogenicpulmonaryoedemabywhichone
ofthefollowing?
A Asymmetricalhypertrophyoftheinterventricularseptumisrevealedonechocardiography
B CalculationofthealveolararterialpO2difference
C Measurementofpulmonaryarterywedgepressure
D Measurementoflungcompliance
E Measurementofejectionfraction
Explanation
TheanswerisMeasurementofthepulmonaryarterywedgepressure
Adultrespiratorydistresssyndrome
Theadultrespiratorydistresssyndrome(ARDS)isaclinicaltriadof
hypoxaemia
diffuselunginfiltrates
reducedlungcompliancenotattributabletocongestivecardiacfailure
Thishasbeenreportedasacomplicationofapparentlyunrelatedconditions,examplesinclude
sepsis
lungcontusion
drugoverdose
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IncreaseinlungwaterinARDSoccursasaresultofanincreaseinalveolarcapillarypermeabilityandisnotdueto
anincreaseinhydrostaticforces.
Distinctionfrompulmondaryoedema
ThisquestionasksyoutorecognisethefeaturesofARDSthataredistinctfrompulmonaryoedemathiscanbea
challengesince,bothclinicallyandradiographically,ARDScloselyresemblesseverehaemodynamicpulmonary
oedemaduetoheartfailure.
Abackgroundofsepsis,lungcontusionordrugoverdosewouldsuggestARDS,whereasahistoryofischaemic
heartdiseaseorcardiomyopathymakescardiogenicpulmonaryoedemamorelikely.
Wedgepressureismeasuredbyinflatingaballoon(aSwanGanzcatheter)inthedistalpulmonaryvesselssuchthat
flowisoccluded:atthispoint,pressuredistaltotheballoonwillreflectthepressureintheleftatrium.Incardiogenic
pulmonaryoedema,wedgepressure(andthereforeLApressure)ishigh.InARDSitisnormal.
ASwanGanzcathetershouldbeplacedifitisunclearwhetherthereisARDSorcardiogenicpulmonary
oedema(thereforeanswerCiscorrect).
Apulmonarycapillarywedgepressureof<18mmHgfavoursacutelunginjuryoverhaemodynamic
pulmonaryoedema.
Asymmetricalhypertrophyoftheinterventricularseptumisrevealedonechocardiography(OptionA)isincorrect.The
presenceofanabnormalventricularseptum(optionA)isnotspecifictoeithertypeofpulmonaryoedema(ARDSor
cardiogenic)andthereforeisnottherightanswer.
CalculationofthealveolararterialpO2difference(OptionB)isincorrect.Incardiogenicpulmonaryoedema,thefluid
presentinthelungscomesfromincreaseinhydrostaticforcesthatovercomestheoncoticforcesthatkeepfluidinthe
capillariesoncethefluidisintheinterstitialspace,alveolarcollapseoccursandthelungbecomesstiffthealveolar
arterialoxygentensiondifferencethenwidensbecausethishappensinbothconditions,answerBcannotdistinguish
betweenthem.
Measurementoflungcompliance(OptionD)isincorrect.LungcomplianceisalteredinbothARDSandpulmonary
oedema,assuchitcannotbeusedtodistinguishbetweenthetwo.
Measurementofejectionfraction(OptionE)isincorrect.InbothARDSandpulmonaryoedema,thecentralvenous
pressureandejectionfractionmaybealteredbutwouldnotreflecttheunderlyingpathophysiologicalmechanismand,
therefore,alone,cannotbeusedtodistinguishthetwoconditions.
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Question198of295
A64yearoldmanwithWolffParkinsonWhitesyndromepresentswithuneasinessandpalpitations.TheECGshows
fineoscillationsofthebaselineandnoclearPwaves.TheQRSrhythmisrapidandirregular.Theventricularrateis120
bpm.Hisbloodpressureis90/60mmHg.
Whichoneofthefollowinginterventionswouldbemostappropriateinthiscase?
A Digoxin
B Verapamil
C DCcardioversion
D Metoprolol
E Procainamide
Explanation
AtrialfibrillationandWolffParkinsonWhitesyndrome
ThispatientmostprobablyhasatrialfibrillationsuperimposedonWolffParkinsonWhite(WPW)syndrome
Theaimoftreatmentistosuppresstheconductionabilityoftheabnormalpathway
ThisisachievedbyusingclassIandIIIantiarrhythmicdrugsbutnotbyverapamilanddigoxin,whichmayallow
ahigherrateofconductionovertheabnormalpathwayandprecipitateventricularfibrillation
ThusneitherverapamilnordigoxinshouldbeusedtotreatatrialfibrillationassociatedwithWPWsyndrome
Previousguidelinessuggestedthatuseofadenosinewasanacceptableoptioninthesepatients,butnowDC
cardioversioninunstablesituationsisseenastheinterventionofchoice,withprocainamideanalternative
CasereportssuggestthattheriskofVFisincreasedinpatientswithWPWwhopresentwithAFwhentheyare
treatedwithadenosine
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Question199of295
A30yearoldmanwithknownhypertrophicobstructivecardiomyopathy(HOCM)presentstocasualtywithanepisodeof
witnessedsyncope:apasserbyprovidedinitialresuscitation.Onadmissionheisunwellwithpulserateof160bpm,blood
pressure70/40mmHganddecreasedconsciouslevel.ECGconfirmsventriculartachycardia.Sinusrhythmisrestored
withaDCshock.
Whatwouldbethemostappropriatestrategyforthelongterm?
A Amiodarone
B Automaticimplantablecardioverterdefibrillator
C Dualchamberpacemaker
D Sotalol
E Verapamil
Explanation
Thismanhassurvivedanoutofhospitalcardiacarrestandthereforeanautomaticimplantablecardioverterdefibrillator
(AICD)iswarranted.Overall,patientswithHOCMhaveanannualmortalityrateofaround1%.Identifyingthoseat
greatestriskofsuddencardiacdeath(SCD)ischallenging.However,severalfactorshavebeenidentifiedthatare
associatedwithanincreasedrisk:
maximumwallthickness>30mm
nonsustainedventriculartachycardiaona48hourtape
ahistoryofSCDinarelativeunder45yearsofageandahistoryofsyncope
resting,leftventricularoutflowtractgradient>30mmHg
abnormalbloodpressureresponsetoexercise.
Althoughasingleriskfactordoesnot,onitsown,haveaparticularlyhighpositivepredictiveaccuracy,thepresenceof
twoormoreriskfactorsdoesidentifyamuchhigherriskpopulation.
Dualchamberpacing,blockersorverapamilmaybeusedtoreducesymptomsinpatientswithaleftventricular
outflowtractobstruction.
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Question200of295
A26yearoldmanisadmittedtotheEmergencyDepartmentafteraroadtrafficcollision.HisECGshowsSTsegment
elevationinleadsV2V5.
Whichoneofthefollowingisthemostlikelycause?
A Coronaryarterydissection
B Localisedpericarditis
C Myocardialcontusion
D MyocardialinfarctionsecondarytothrombosisofRCA
E Pericardialeffusion
Explanation
TheanswerisMyocardialcontusion
Chestinjuries
Roadtrafficinjuriesareacommoncauseofbluntchesttrauma.Thismostcommonlycausesmyocardialcontusion.
Chesttraumacanalsocause:
myocardialrupture
aorticrupture
valveinjury
lacerationsorthrombosisofthecoronaryarteriesthesearefairlyrare
Allofthesearerapidlyfatalunlessimmediatetreatmentisgiven.
Myocardialcontusionwillcausechestpainandcardiacfailureduetoacuteimpairment.Patientsmayhavea
pericardialrub,agallop(S3)andhaveSTchangesanteriorly.HeartblockandRBBBmayalsobepresent.Urgent
echocardiographyshouldbeperformed.
Alocalisedpericariditisisunlikely.
Localisedinjurytothesinoatrialoratrioventricularnodesmaycausearrhythmias.
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Coronaryarterydissection(OptionA)isincorrect.Thiswouldnotbethemostlikelycauseinthiscase.
Localisedpericarditis(OptionB)isincorrect.Thiswouldnotbethemostlikelycauseinthiscase.
MyocardialinfarctionsecondarytothrombosisofRCA(OptionD)isincorrect.Thiswouldnotbethemostlikelycausein
thiscase.
Pericardialeffusion(OptionE)isincorrect.Thiswouldnotbethemostlikelycauseinthiscase.
42027
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Question201of295
A53yearoldbusdriverpresentswithahistoryofchestpainatrest.InitialECGshowsminorSTsegmentdepressionin
thelateralleads.Cardiacenzymes,includingtroponin,arenormal.Hehasknownangina,withangiography3years
previouslydemonstratingminorrightcoronaryarterydisease,forwhichhewasusingaGTNsprayonly12timesper
year.Henormallygoestothegymseveraltimesaweek.Heiscommencedonaspirin,ablockerandastatin.His
symptomssettleover24hours,12hourtroponinisnormaland,followingmobilisation,heisdischargedhome.Heneeds
toknowhowthisepisodemightaffecthisfutureemployment.
Assuminghisconditionremainsstablewithnofurthersymptoms,whatwouldbethenextstageofinvestigationwith
respecttohisregaininghisbusdrivinglicence?
A Angiography
B Echocardiogram
C Exercisetesting
D Myocardialperfusionimaging
E Reviewinoutpatientsafter6weeks
Explanation
TheanswerisExercisetesting
CoronaryarterydiseaseandDVLAregulations
KnowledgeoftheDVLAregulationsforcoronaryarterydiseaseisessentialforallpartsoftheMRCPexamination.
EnsureyouarefamiliarwiththelatestuptodateguidelinesavailablefromtheDVLAwebsite(www.dvla.gov.uk).
Thismanholdsagroup2licence,andhenceheshouldbeadvisedtoinformtheDVLAofhisrecentpresentation
withunstableangina(atypeofacutecoronarysyndrome)andstopworkuntilrelicensingcanbeperformed.
Forgroup2licenceholders,allacutecoronarysyndromesareconsideredrelevantandthisdisqualifiestheindividual
fromdrivingforatleast6weeks.Inthisman,althoughhistroponinisnegative,thepainatrestcountsaspartofthe
acutecoronarysyndrome.
Relicensingmaybepermittedifasuitableexercisetestisachieved(needtocompletethreestagesoftheBruce
protocol(typicallyatleast8minutesoftheBruceprotocol),withoutantianginalmedicationfor48hoursandwithout
significantsymptoms,ECGorhaemodynamicabnormalities)andtherearenootherdisqualifyingconditions.
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Notethatantianginalmedicinesincludenitrates,blockers,calciumchannelblockers,nicorandil,ivabradineand
ranolazineprescribedforantianginalpurposesorforotherreasons,egcardioprotection.
Angiography(OptionA)isincorrect.Angiographyisarelevantinvestigationforthispatientandshouldbeconsidered
clinically.However,itisnotrequiredforrelicensingandthereforeisnottheanswerinthisquestion.Ifhewentonto
havePCI,thenhewouldbedisqualifiedfor6weeksandneedtoperformanexercisetestasabove.
Echocardiogram(OptionB)isincorrect.Echocardiogramisincorrectasitdoesnotstatestressechocardiographyandit
appearsthepatientcanexercise.
Myocardialperfusionimaging(OptionD)isincorrect.Inpatientswhocannotexerciseduetodisability,thenstress
echocardiographyormyocardialperfusionimagingmaybesuitable,providedtheLVEFis>40%andnomorethan10%
ofthemyocardiumisaffectedbyreversibleischaemicchange.Inthisquestion,itstatesthatthepatientgoestothegym,
makingitlikelythathecanperformtheexercisetestratherthanhavingtohavethemyocardialperfusionimaging.
Reviewinoutpatientsafter6weeks(OptionE)isincorrect.Thiswillnothelphimregainhislicence.
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Question202of295
A54yearoldmanisreferredwithincreasedswellingofhisanklesandabdomen,andadegreeofshortnessofbreathon
exertion.Hisjugularvenouspressure(JVP)iselevatedwithprominentxandydescents.Apexbeatisnormal.ECG
showsatrialfibrillationwithwidespreadnonspecificSTsegmentabnormalities.Echorevealspreservedleftventricular
systolicfunctionwithbiatrialenlargementandanestimatedpulmonaryarterysystolicpressureofaround60mmHg.Chest
Xrayshowsatrialenlargementbutnootherabnormalities.
Whatisthemostlikelycardiacdiagnosis?
A Chronicpulmonaryemboli(PE)
B Dilatedcardiomyopathy
C Restrictivecardiomyopathy
D Secundumatrialseptaldefect(ASD)
E Tricuspidregurgitation
Explanation
TheanswerisRestrictivecardiomyopathy
Thepresenceofprominentxandydescentsshouldimmediatelyraisethesuspicionofrestrictiveheartdisease.
Restrictivecardiomyopathy
Restrictivecardiomyopathyresultsfromfibrosisorinfiltrationoftheendoormyocardium.
Theresultisfailureoftheventriclestorelax,withasubsequentincreaseinventricularenddiastolicpressures
leadingontobiatrialenlargement.
Systolicfunctionisnormal.
Causes
Underlyingcausesinclude
amyloidosis
storagedisorders
sarcoidosis
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haemochromatosis
endomyocardialfibrosis.
Differentiation
Itcanbeverydifficulttodifferentiaterestrictivecardiomyopathyfromconstrictivepericarditis.
Inrestrictionthepulmonaryarterysystolicpressureisusuallyelevatedto>45mmHg,whileitislowerin
constriction.
Rightandleftheartcathetermayaiddifferentiation.
Othernotes
Symptomsareusuallythoseofpredominantrightheartfailureandatrialfibrillationiscommon.
TheECGmaybenormalbutdiffuseSTsegmentandTwavechangesarecommonlyseen.
Diureticsarethemainstayofsymptomatictreatment.
ChronicPE(OptionA)isincorrect.ChronicPEcouldbeconsideredsincethepulmonarypressuresaresignificantly
raised,butitdoesnotexplainthexandydescentsontheJVP.
Dilatedcardiomyopathy(OptionB)isincorrect.Dilatedcardiomyopathyisnotcorrectastheleftventricularfunctionis
preserved.
SecundumASD(OptionD)isincorrect.AsecundumASDwouldtypicallybevisualisedonanechocardiogramand
wouldbeassociatedwithrightbundlebranchblock(RBBB)ontheECGandfixedsplittingofthesecondheartsound.
Tricuspidregurgitation(OptionE)isincorrect.TricuspidregurgitationisassociatedwithgiantcVwavesintheJVPwhich
arenotpresenthere.
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Question203of295
A72yearoldwhitewomanisreferredtooutpatientsforadviceregardingherhypertensionmanagement.Shehasbeen
ontreatmentintheformofperindopril4mgodforthepast3years.However,onrepeatedmeasurements,herreadings
havebeen>160mmHgsystolic,withdiastolicreadingsbeingintheorderof8085mmHg.Renalfunctionisnormalasis
urinedipsticktesting.ThereisnoevidenceofleftventricularhypertrophyonECG.Sheisobesewithabodymassindex
of33kg/m2.
Whatwouldyouconsideraddingasyournextdrug?
A Atenolol
B Bendrofluazide
C Doxazosin
D Amlodipine
E Spironolactone
Explanation
TheanswerisAmlodipine
Hypertensionmanagment
Thiswomanhashypertensionresistanttoasingleagentitisincreasinglyrecognisedthatmorethanoneagentis
requiredtoadequatelycontrolbloodpressure.Lowdosesofmorethanoneagentcanbemoreeffectivethan
increasinglythedoseofasingleagent.Doseincreasemayleadtolittleadditionalgainandonlysideeffects.
Toanswerthisquestion,yousholdbeawareoftheguidelinesforhypertension.ShehasBPhigherthan140/80
despiteonemedicationrepeatedbloodpressuresover160systolicshouldbetreatedforprimarypreventionofstroke
andmyocardialinfarction.
FigurereproducedfromtheNICEguidelines2011:
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SheisonAoftheguidelinesanACEinhibitor:thereforethenextbestagenttoaddisCcalcium
channelantagonist:thereforeamlodipineistheonlycorrectanswer.Itcanbearguedthatsheshouldhave
beenstartedonamlodipineasthefirstlineagent.Regardlessofthis,alltheotheranswerswouldbe
consideredonlyafterbothagentswereonboard
Ifshecontinuestobehypertensiveafterthis,thenaddbendroflumethazidespironolactoneshouldbeusedif
thisfails
blockershavenowbeenremovedfromroutineuseinhypertensionsince,despitetheirinitialevidencebase,
theyhaveonlyasmallaffectonbloodpressure
Atenolol(OptionA)isincorrect.AsdescribedthiswouldbeconsideredonlyonceAandCwereonboard.
Bendrofluazide(OptionB)isincorrect.AsdescribedthiswouldbeconsideredonlyonceAandCwereonboard.
Doxazosin(OptionC)isincorrect.AsdescribedthiswouldbeconsideredonlyonceAandCwereonboard.
Spironolactone(OptionE)isincorrect.AsdescribedthiswouldbeconsideredonlyonceAandCwereonboard.
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Question204of295
A71yearoldwomanwithahistoryofonepreviousmyocardialinfarctionpresentstotheEmergencyDepartment.She
hassuddenonsetshortnessofbreathandpalpitations,whichhappenedafterherdinneracoupleofhoursearlier.A
previousECGfromclinicamonthearliershowssinusrhythm.Medicationincludesramipril10mgdaily,amlodipine10
mgdailyandaspirin75mg.Onexaminationherbloodpressureis100/60mmHg,herpulseis140bpmirregularandshe
hasevidenceofleftventricularfailure.Clinicalresultsaregiveninthetablebelow:
Hb 14.0g/dl
WCC 6.7109/l
PLT 190109/l
Na+ 140mmol/l
K+ 5.0mmol/l
Creatinine 130mol/l
ECG fastatrialfibrillation,lateralSTdepression
Whichoneofthefollowingisthemostappropriatemedicationtocontrolheratrialfibrillation?
A Digoxin
B Amiodarone
C Flecainide
D Sotalol
E Verapamil
Explanation
Treatmentofatrialfibrillation
Flecainide,althougheffectiveatcardiovertingatrialfibrillation,iscontraindicatedinpatientswithahistoryof
ischaemicheartdisease,astheCASTpostinfarcttrialdemonstratedincreasedmortalityinpatientstreatedwith
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flecainide
Sotalolandverapamilarenegativelyinotropicandlikelytoworsenleftventricularfailure
Digoxinwouldbeeffectiveatslowingtheventricularrate,butgiventhatthepatientwasinsinusrhythm1month
earlier,itwouldbeareasonableobjectivetoattainsinusrhythmagain
Assuch,ivloadingwithamiodaronewouldappeartobethemostappropriateoptioninthispatient
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Question205of295
A20yearoldwomanpresentswithahistoryofdyspnoeaonexertion.Onexaminationshehasawide,fixed,splitsecond
soundwithanejectionsystolicmurmurintheleftsecondintercostalspace.HerECGshowsleftaxisdeviation.
Whatisthemostprobablediagnosis?
A Aorticstenosis
B Ostiumprimumseptaldefect
C Ostiumsecundumseptaldefect
D Pulmonarystenosis
E Tricuspidincompetence
Explanation
TheanswerisOstiumprimumseptaldefect
Systolicmurmurs
Septaldefects
Wide,fixedsplittingofS2withanejectionsystolicmurmurintheleftsecondintercostalspacepointstoa
diagnosisofatrialseptaldefectthereforethepotentialanswersareostiumprimumseptaldefectorostiumsecundum
septaldefect.
Leftaxisdeviationoccursinostiumprimumatrialseptaldefect,whereasrightaxisdeviationisseeninostium
secundumseptaldefect.Therefore,thecorrectanswerisostiumprimumseptaldefect.
TheASDwillshuntbloodfromtheleft(highpressure)totherightsideoftheheart(lowpressure).Thismeans
thereisalargevolumeofadditionalbloodpassingthroughthepulmonaryvalvesintothepulmonaryarterythis
createstheejectionsystolicmurmur.
Pulmonarystenosiswilldelaytheclosureofthepulmonaryvalve,meaningthatthegapbetweenA2andP2is
accentuated.Similarly,inaorticstenosis,theA2closureisdelayed.However,inboththesecases,thesplittingisnot
fixedandwillvarywithrespiration.Inthiscase,thesplittingisfixed(doesnotvarywithrespiration),whichmeans
pulmonarystenosisandaorticstenosisareunlikely.
Aorticstenosisisassociatedwithanejectionsystolicmurmurthatiscrescendodecrescendo.
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Inpulmonarystenosis,thereisaharshmidsystolicejectionmurmur,bestheardoninspirationtotheleftofthe
sternuminthesecondintercostalspace.
Aorticstenosis(OptionA)isincorrect.Inaorticstenosis,theA2closureisdelayed.Thesplittingisnotfixedandwillvary
withrespiration.Inthiscase,thesplittingisfixed(doesnotvarywithrespiration),whichmakesaorticstenosisunlikely.
Ostiumsecundumseptaldefect(OptionC)isincorrect.Rightaxisdeviationisseeninostiumsecundumseptaldefect.
Pulmonarystenosis(OptionD)isincorrect.Pulmonarystenosiswilldelaytheclosureofthepulmonaryvalve,meaning
thatthegapbetweenA2andP2isaccentuated.Thesplittingisnotfixedandwillvarywithrespiration.Inthiscase,the
splittingisfixed(doesnotvarywithrespiration),whichmakespulmonarystenosisunlikely.
Tricuspidincompetence(OptionE)isincorrect.Tricuspidincompetencewouldleadtoapansystolicmurmur,whichis
bestheardoninspirationatthelowersternaledgethemurmurcanbeveryquietunlessthereiselevatedpulmonary
pressureaswell.SignificantTRwillcausegiantVwavesontheJVP.
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Question206of295
Apatientwhohasbeeninadvertentlygivenanintravenousinjectionofpotassiumchloridedevelopsventricular
tachycardia.Hispulseis150bpmandbloodpressure60/40mmHg.
Whatwouldbethebestfirstlineoftreatmentinthiscase?
A 10mlof10%calciumgluconate
B Amiodarone
C DCcardioversion
D Insulin10unitsand50mlof50%glucose
E Lidocaine
Explanation
TheanswerisDCcardioversion
ManagementofVTsecondarytohyperkalaemia
Sincethepatientishaemodynamicallycompromised,thefirstemergencystepisimmediatelytoperformDC
cardioversion(DCCV)otherwiseVTwillbecomeVFleadingtodeath.
10mlof10%calciumgluconate(OptionA)isincorrect.Injectionof10mlof10%calciumgluconatewouldhelpto
protectthemyocardiumagainsthyperkalaemiaandtheinitiationofVT.Itistypicallyusedinamonitoredenvironment.
Calciumionsprotectthecellmembranesfromtheeffectsofhyperkalaemiabutdonotalterthepotassiumconcentration
andadditionaltherapyisrequiredtoreducethepotassium.Inthiscasethepatientisalreadycompromisedandneeds
immediateDCCV.
Amiodarone(OptionB)isincorrect.AmiodaroneisonlyusefulinhaemodynamicallystablecasesofVT.Amiodaroneis
firstline.
Insulin10unitsand50mlof50%glucose(OptionD)isincorrect.Acominationofinsulinandglucoseistypicallyused
toreducepotassiumlevels.Insulindrivespotassiumintothecellandmustbeaccompaniedbyglucosetoavoid
hypoglycaemia.This,togetherwiththecalciumgluconate,wouldbeperformednextaftertheDCCV.
Lidocaine(OptionE)isincorrect.LidocaineisonlyusefulinhaemodynamicallystablecasesofVT.Lidocaineisusedfor
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resistantcases.
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Question207of295
A30yearoldmanwithknownhypertrophicobstructivecardiomyopathy(HOCM)presentstotheEmergencyDepartment
withanepisodeofwitnessedcollapse:apasserbyprovidedinitialresuscitationwhenhefeltnopulseandthemanwas
makingnoefforttobreathe.Onadmissionheisunwellwithpulserateof160bpm,bloodpressure70/40mmHgand
decreasedconsciouslevel.ECGconfirmsventriculartachycardia.SinusrhythmisrestoredwithaDCshock.
Whatwouldbethemostappropriatestrategyforthelongterm?
A Amiodarone
B Automaticimplantablecardioverterdefibrillator
C Dualchamberpacemaker
D Sotalol
E Verapamil
Explanation
Longtermmanagementofhypertrophicobstructivecardiomyopathyaftercardiacarrest
Thismanhassurvivedanoutofhospitalcardiacarrestandthereforeanautomaticimplantablecardioverter
defibrillator(AICD)iswarranted
Overall,patientswithHOCMhaveanannualmortalityrateofaround1%
Riskfactors
Identifyingthoseatgreatestriskofsuddencardiacdeath(SCD)ischallenging
Severalfactorshavebeenidentifiedthatareassociatedwithanincreasedrisk
maximumwallthickness>30mm
nonsustainedventriculartachycardiaona48hourtape
ahistoryofSCDinarelativeunder45yearsofageandahistoryofsyncope
resting,leftventricularoutflowtractgradient>30mmHg
abnormalbloodpressureresponsetoexercise
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Althoughasingleriskfactordoesnot,onitsown,haveaparticularlyhighpositivepredictiveaccuracy,the
presenceoftwoormoreriskfactorsdoesidentifyamuchhigherriskpopulation
Treatment
Dualchamberpacing,blockersorverapamilmaybeusedtoreducesymptomsinpatientswithaleftventricular
outflowtractobstruction
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Question208of295
A56yearoldmanpresentswithacardiacrhythmdisorder.Whichoneofthefollowingscenarioswouldbeanindication
fortemporarytransvenouscardiacpacemakerinsertion?
A Asymptomatic2.8ssinuspauses
B Ashortperiodofcompleteheartblockcomplicatinginferiormyocardialinfarction(prethrombolysis)with
bloodpressure110/70mmHg
C Asymptomaticcompleteheartblockwithbroadcomplexventricularcomplexesat35bpm
D MobitzIIAVblockcomplicatinganteriormyocardialinfarctionwithbloodpressure110/70mmHg
E Bifascicularblockpriortoaorticaneurysmrepair
Explanation
Needforatransvenouscardiacpacemaker
Asymptomaticsinusnodedisease,evenwithprolongedpauses,carriesalowriskofsuddendeathandcanusually
bemanagedwithoutatemporarywire
Chroniccompleteheartblockhasahigherrisk,butifasymptomaticandwithastableescaperhythmcanalsobe
managedinmostcaseswithoutatemporarywire
Bifascicularblockcarriesaslightlyhigherriskofhighgradeatrioventricular(AV)blockbut,inasysmptomatic
patients,thisriskissufficientlylowtoobviatetheneedforperioperativepacing
Inmyocardialinfarction,AVblockandevencomplicatingMIshouldbemanagedconservativelyifasymptomatic
andcausingnohaemodynamiccompromise
However,secondorthirddegreeheartblockcomplicatinganteriorMIrequirespacing
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Question209of295
A72yearoldmancomestotheclinicforreview.HehashadseveralrandombloodpressurescheckedathisGPoverthe
courseof3months,whichindicateanaverageBPof171/80mmHg.Systolichypertensionisconfirmedon24hrABPM.
Hehasapasthistoryofasthma,whichiswellcontrolledwithuseofaPRNSalbutamolinhalerbeforeexercise.
ExaminationintheclinicconfirmsthesystolichypertensionhisBMIis23.Therearenoothersignificantfindings.
Whichofthefollowingisthemostappropriateintervention?
A Amlodipine
B Bendroflumethiazide
C Bisoprolol
D Ramipril
E Valsartan
Explanation
TheanswerisAmlodipine
NICEguidelinesrecommendmanagingisolatedsystolichypertensioninthesamewayasotherformsofhypertension
withacalciumchannelantagonisttheinterventionofchoiceinapatientaged55orgreater,orwhoisofAfroCaribbean
descent.Step2ifBPisnotcontrolledinthissituationistoaddanACEinhibitororARB.Athiazidelikediureticsuchas
Indapamide(ratherthanathiazidesuchasBendroflumethiazide)isaddedforpatientswhoarenotattheirtargetBPon
twoagentsorcanbeusedasanalternativetoacalciumchannelantagonistifthisisnottolerated.
http://www.nice.org.uk/guidance/CG127(http://www.nice.org.uk/guidance/CG127)
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Question210of295
A60yearoldladypresentstotheCardiologyClinic.Shehassufferedincreasingshortnessofbreathanddecreased
exercisetoleranceoverthepastfewmonths.OnexaminationherBPis145/75mmHg,pulseis75/min,atrialfibrillation.
Therearebilateralcracklesonauscultationofthechest.Youarrangeforhertohaveanechocardiogram.
Whichoneofthefollowingismostlikelytoleadtoanincreaseinenddiastolicleftventriculardimensionsandpressurein
thispatient?
A Hypertrophiccardiomyopathy
B Mitralstenosis
C Pericardialeffusion
D Pulmonarystenosis
E Severemitralregurgitation
Explanation
TheanswerisSeveremitralregurgitation
Leftventriculardysfunction
Althoughtheclinicalscenariocanhelpyouhaveaframeofreference,itispossibletoanswerthequestionwithoutit.
Onlyoneoftheconditionslisted(Severemitralregurgitation)canraiseleftventricularenddiastolicpressure.
Anyotherconditionwhichcausesincreasedleftventricularwork(egtoovercomeleftventricularoutflow
obstructioninaorticstenosis)orincreasedleftventricularenddiastolicpressure(eginendstagemitral
regurgitation)willeventuallycauseLVdilatation.ThispatientistypicalofsomeonewithdilatedLVandmitral
regurgitation.Thepresenceofmitralregurgitationmeansmuchofthebloodvolumereturnstotheleftatrium,and
thenbackintotheLV.OvertimetheLVwillbedilatedandpressuresattheendofdiastole(whentheLVshouldbe
empty,havingejectedalltheblood)becomeraised.ThisleadstoLVdilatation,whichinitselfcancontributeto
mitralregurgitation:asthemitralannulusbecomesstretchedpullingapartthemitralleaflets,therewillbeafailureof
coaptationandworseningMR.
Hypertrophiccardiomyopathy(OptionA)isincorrect.Inhypertrophiccardiomyopathysevereleftventricularhypertrophy
preventssignificantincreaseinintracavitydimensionssuchasLVenddiastolicdimensionsandpressure.
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Mitralstenosis(OptionB)isincorrect.Mitralstenosisdoesnotaffectleftventricularworkloadandthereforethereisnot
dilatationoftheleftventricle.
Pericardialeffusion(OptionC)isincorrect.Inpericardialeffusion,pericardialfluidpreventsLVdilatationbyexternal
compression.
Pulmonarystenosis(OptionD)isincorrect.Pulmonarystenosisdoesnotaffectleftventricularworkloadandtherefore
thereisnotdilatationoftheleftventricle.
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Question211of295
A65yearoldmanisreferredtooutpatientswithresistanthypertension.Heisalreadytakingbendrofluazide2.5mgonce
daily,lisinopril20mgoncedailyandamlodipine10mgoncedaily.Heisanexsmokerwithapasthistoryof
uncomplicatedmyocardialinfarction.Bloodpressureis170/100mmHginbotharms.Theonlyotherabnormalityon
examinationisaleftfemoralbruit.Resultsofinvestigationsareasfollows:LVHonECGcreatinine,165mol/litre
sodium,138mmol/litrepotassium,4.1mmol/litrechestXray,normal24hourbloodpressure,sustainedsystolicand
diastolichypertensionwithnoevidenceofnocturnaldip.
Whatisthemostlikelyunderlyingaetiologyforhishypertension?
A Coarctation
B Connsyndrome
C Cushingsyndrome
D Polycystickidneydisease
E Renalarterystenosis
Explanation
TheanswerisRenalarterystenosis
ThispatienthassignificanthypertensionwithevidenceofsecondaryharmLVHandraisedcreatinine.Heistaking
threemedications(oneofwhichisadiuretic)andcontinuestohaveelevatedlevelsthisisresistanthypertension.
Asecondarycauseforhypertensionismorelikelyinpatientswithresistanthypertensionandinthosewhofailto
showanocturnaldip(usuallyanapproximately20%dropinBPoccursatnight)
Alloftheanswersarecausesofsecondaryhypertension.
Inthiscase,renovasculardiseaseshouldbesuspectedsincehehasdocumentedevidenceofcomorbidvascular
diseaseandarterialbruit
Adiscrepancyinrenalsizeonultrasoundwouldaddfurtherweighttothediagnosis.
Furtherimaging,suchasangiographyormagneticresonanceangiography,shouldbeconsideredinpatients
withahighindexofsuspicionforrenovasculardisease.
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Coarctation(OptionA)isincorrect.Coarctationmaypresentwithadifferentialinbloodpressuresinbotharmsalthough
thisonlyoccursifthecoarctationisproximaltotheleftsubclavian,whichonlyoccursinonesixthofcases.Patientswith
significantcoarctationmayhavealoudsystolicmurmurandmayhaveclaudicationtypesymptomsinthelegs,with
absentordiminishedfemoralpulses.Neitherispresentinthisscenario.
Connsyndrome(OptionB)isincorrect.Connsyndromeisunlikelybecausethepotassiumisnotlow
Cushingsyndrome(OptionC)isincorrect.Cushingsyndromewouldhavethepresenceofweightgain,abdominalstriae,a
moonfaceandabuffalohumponthenecknoneispresenthere.
Polycystickidneydisease(OptionD)isincorrect.Polycystickidneysmaybepalpableonexaminationitismuchless
commonthanrenalarterystenosisandthereforelesslikelytobetheanswer.
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Question212of295
Whichoneofthefollowingarrhythmiasisunusualindigoxintoxicity?
A Nonparoxysmalatrialtachycardiawithvaryingblock
B Firstdegreeheartblock
C TypeIIseconddegreeheartblock
D Wenckebachphenomenon
E Bidirectionalventriculartachycardia
Explanation
TheanswerisTypeIIseconddegreeheartblock
Digoxincancauseamultitudeofdysrhythmias,duetoincreasedautomaticity(increasedintracellularcalcium)and
decreasedAVconduction(increasedvagaleffectsattheAVnode).
Theclassicdysrhythmiathatoccursduringdigoxintoxicityisthecombinationofasupraventriculartachycardia(due
toincreasedautomaticity)withaslowventricularresponse(duetodecreasedAVconduction),egatrialtachycardia
withblock.
DigoxintoxicitycanresultinanyabnormalcardiacrhythmexcepttypeIIseconddegreeatrioventricular(AV)block.
Sincethisquestionaskswhicharrhythmiawouldbeunusualthen,optionCmustbecorrect.Theotheroptionscan
alloccurandthereforearefalseforthisquestion.
Theothercommonarrhythmiasinclude
firstdegreeheartblock
Wenckebach(typeIseconddegreeblock)andcomplete(thirddegree)heartblock
ventricularectopicsandventriculartachycardia(VT)(uniandbidirectional)
Ventricularfibrillation(VF)canalsorarelyoccur.Anotherunusualarrhythmiaisatrialflutter.
Predisposingfactors
Factorspredisposingtodigitalistoxicityare
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advancedage
hypoxia
hypokalaemia(mostcommonprecipitatingfactor)
hypomagnesaemia
hypercalcaemia
hypothyroidism
amyloidosis
renalfailureSignsandsymptoms
Theearliestsignsofdigitalistoxicityinclude
nausea
vomiting
anorexia
Chronictoxicitycauses
exacerbationofheartfailure
weightloss
gynaecomastia
yellowvision
Nonparoxysmalatrialtachycardiawithvaryingblock(OptionA)isincorrect.Thiscanoccurindigoxintoxicityandso
wouldnotbeanunusualfinding.
Firstdegreeheartblock(OptionB)isincorrect.Thiscanoccurindigoxintoxicityandsowouldnotbeanunusual
finding.
Wenckebachphenomenon(OptionD)isincorrect.Thiscanoccurindigoxintoxicityandsowouldnotbeanunusual
finding.
Bidirectionalventriculartachycardia(OptionE)isincorrect.Thiscanoccurindigoxintoxicityandsowouldnotbean
unusualfinding.
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Question213of295
A65yearoldmanpresentstotheEmergencyDepartment2daysaftersufferingseveralhoursofseverechestpain.Heis
currentlypainfree.ECGshowsfixedanteriorSTsegmentelevation.Heiscommencedonaspirin,ablocker,anACE
inhibitorandastatin.Angiographyshowsocclusionofhisleftanteriordescendingartery(LAD),whichistreatedwith
angioplastywithasinglestent.Echocardiographysuggeststherehasbeencompleteanteriorwallinfarctionatthemid
ventricularleveltotheapex.Hisinitialprogressiscomplicatedbyfurtherpain,worsewithinspirationandmovementand
relievedbynonsteroidaldrugs.Youarecalledtoseehimonday5postinfarct,whenhecomplainsofshortnessofbreath
onwalkingtothebathroom.Helooksunwellwithacoolperipheryandrestingtachycardia.Bloodpressureisreducedat
90/50mmHg.Jugularvenouspressure(JVP)iselevatedtoaround8cmandriseswithinspiration.HisECGshowssmall
complexeswithsinustachycardia.ChestXrayshowsanincreaseinthecardiothoracicratiobutclearlungfields.
Whatisthemostlikelycomplicationtohavedevelopedtoaccountforthisdeterioration?
A Cardiogenicshock
B Mitralregurgitation
C Pericardialtamponade
D Pulmonaryembolism
E Ventricularseptaldefect
Explanation
TheanswerisPericardialtamponade
Devastatingcomplicationsstilldooccurfollowingacutemyocardialinfarctionthisisparticularlytrueinthosethat
presentlateandthosewithcompletionoftheinfarctiondespitetherapy.Inthiscase,althoughhisLADwasstented
open,theinfarctionhappened48hourspriortohisarrivalinhospitalanditappearstheterritorywasfullyinfarcted.
Primarypercutaneouscoronaryintervention(PCI)andthrombolysisshouldoccurwithin12hoursofthepainfor
maximalbenefitafter48hoursthereislikelynobenefit.Alloftheanswersarepossiblereasonsforthis
presentation.
Pericardialtamponadeisthemostlikelyanswerandthereareseveralfeaturesconsistentwithit.
KussmaulssigntheincreaseinJVPwithinspiration.
EnlargedheartonchestXraywithclearlungs.
ECGcomplexesaresmallandmayalternateinsizebeattobeat:theheartisencasedinfluidandtherefore
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isfurtherawayfromtheECGelectrodes,orflopsaroundinthefluidcausingchangingcomplexsize.
Thepainoninspirationlikelyrepresentedaphaseofpericarditisinresponsetothefullthicknessinfarction,
whichleadstoaninflammatoryresponseandcollectionofblood/fluidinthepericardialsac.
ThefirstchambertobecompressedistherightatriumthiselevatestheJVPandcausesKussmaulssign.
ThiswillimpairrightventricularfillingandtriggerRVcollapseatthispoint,deathbecomesimminent.
Immediateechocardiographyisrequiredanddrainageofthefluid.
Cardiogenicshock(OptionA)isincorrect.Cardiogenicshocktendstooccurearlyfollowingalargeinfarct(orinthe
presenceofalreadyimpairedleftventricularfunction),butthisistypicallyearly,eginthefirst2448hours.Inthiscase,it
develops5dayslater,makingitlesslikely.
Mitralregurgitation(OptionB)isincorrect.Thedevelopmentofacutemitralregurgitationisassociatedwithsevere
pulmonaryoedemainthiscase,thelungsareclearrulingthisout.
Pulmonaryembolism(OptionD)isincorrect.PulmonaryemboliwouldbeanunusualcomplicationofMI.PEscancause
rightventricularinfarction,butwouldnotbethemostlikelycomplicationhere.
Ventricularseptaldefect(OptionE)isincorrect.Thedevelopmentofventricularseptaldefectisassociatedwithsevere
pulmonaryoedemainthiscase,thelungsareclearrulingthisout.
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Question214of295
A53yearoldwomanwhohashadchemotherapyformetastaticbreastcancer6monthsearliercomestotheclinic
complainingofshortnessofbreathonexertion.HerBPis125/78mmHg,herpulseis94bpmandherapexbeatis
displacedtotheanterioraxillaryline.Clinicalresultsaregiveninthetablebelow:
Hb 11.9g/dl
WCC 5.0109/l
PLT 190109/l
Na+ 140mmol/l
K+ 4.5mmol/l
Creatinine 160mol/l
CXR cardiomegaly,increasedshadowingconsistentwithmildpulmonaryoedemaatbothbases
Whichoneofthefollowingchemotherapeuticagentsismostlikelytoberesponsibleforthispatient'ssymptoms?
A Doxorubicin
B Docetaxel
C Cisplatin
D Bleomycin
E Carbiplatin
Explanation
Doxorubicin
Doxorubicincanbeassociatedwithcardiacfailure,reducedleftventricularejectionfractionand
tachyarrhythmias.Itisfrequentlyusedinthetreatmentofsmallcelllungcancer,breastcancerandmetastatic
ovariancancer
RegularECGs,CXRandEchocardiogramsarerecommendedtoruleoutthepossibilityofLVFbeforestarting
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therapyandatregularintervalsduringtreatment
Othernotes
Docetaxelmayalsobeassociatedwitharrhythmiasandcardiacfailure,althoughthelikelihoodislessthanwith
doxorubicin
Platinumbasedchemotherapiesareassociatedwithnervedamage
Bleomycinisassociatedwithinterstitialpneumonitis
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Question215of295
A75yearoldmanisreferredfortotalhipreplacement.Hehasahistoryofhypertensionandsufferedamyocardial
infarctionsome3yearsearlier,whichwastreatedwithPCI.Hehasnoanginacurrently.Currentmedicationincludes
bisoprolol10mgdaily,ramipril10mgdaily,aspirin75mgdailyandisosorbidedinitrate60mg.Bloodpressureatthe
preoperativeassessmentwas140/80mmHg.Helasthadanexercisetestsome3monthsearlierandmanaged9minwith
nosignificantelectrocardiogram(ECG)changes.
Whichoneofthefollowinginvestigationsinadditiontostandardassessmentwouldbemostappropriateforthe
preoperativeassessmentofthispatient?
A 99TcmMIBISPECTscan
B Cardiacmagneticresonanceimaging
C DobutaminestressECG
D RepeatexerciseECGtest
E Transthoracicechocardiogram
Explanation
TheanswerisTransthoracicechocardiogram
Preoperativeassessment
Thispatienthasapriormyocardialinfarctionbuthashadnoanginalsymptoms.Heappearsstableandhada
recentexercisetestthatsuggeststhereisnosignificantischaemia.Thevalueofadditionalstresstestsinan
asymptomaticpatientarethereforelimitedandthusoptionsA,CandDarenotthebestanswers.Ifthe
patienthadsymptomsthenquantificationandconfirmationofischaemiawouldbeappropriate,whereupon
thesewouldbeconsidered.
Routineechocardiogramwouldaddinformationaboutleftventricularfunctionandpointoutanyvalvulardisease
thesewillbeimportantforsurgerysuchastotalhipreplacement,wherebloodlosscouldcausesignificant
haemodynamicchanges.KnowingLVfunctionandvalvediseaseisimportanttomanagetheseappropriately.
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Therefore,transthoracicechoandcardiacmagneticresonanceimagingarepossibleanswers.Transthoracic
echocardiographywouldprovidesufficientinformationabouttheLVfunctionandthebestinformationaboutthe
valvesandthereforeisabetteranswerthancardiacMRI.
99TcmMIBISPECTscan(OptionA)isincorrect.Thevalueofadditionalstresstestsinanasymptomaticpatientare
thereforelimited.
Cardiacmagneticresonanceimaging(OptionB)isincorrect.Iftherewasaquestionovermyocardialviabilityorsizeof
thescarthenthiswouldbethebestoption,butinthisinstancetransthoracicechocardiogrameisbetter.
DobutaminestressECG(OptionC)isincorrect.Thevalueofadditionalstresstestsinanasymptomaticpatientare
thereforelimited.
RepeatexerciseECGtest(OptionD)isincorrect.Thevalueofadditionalstresstestsinanasymptomaticpatientare
thereforelimited.
42025
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Question216of295
WhatisthecommonestcauseofrestrictivecardiomyopathyintheUK?
A Pompedisease
B Amyloidosis
C Endocardialfibroelastosis
D Carnitinedeficiency
E Acutecoxsackievirusinfection
Explanation
TheanswerisAmyloidosis
Restrictivecardiomyopathiesareconditionsinwhichthemyocardiumisabnormalincontrast,constrictiveheart
diseaseiswherethepericardiumisabnormal.Bothinvolveanimpairmentofdiastolicfilling,whichleadstoa
reductionincardiacoutput.Systolicfunctionmayappeartobenormalinitially.Themostcommonresistrictive
cardiomyopathyintheUKiscausedbyamyloidosis.
Amyloidosisisnotasingledisorder,ratheragroupofdisordersthatproduceaproteinwithaparticularpatternthat
thenaggregateswithintheorgans.Amyloidproteinismadeupofnonbranchingfibrilsarrangedinpleatedsheets
theproteinisinsolubleandresistanttobreakdownandsoaccumulatesinanyorgan.Ifitaccumulatesintheheart,it
causesamyloidheartdisease,whichhasaverypoorprognosis.
Conditionsthatcantriggeramyloidosisaremanyandincludeanychronicinflammatorydisorder,suchasrheumatoid
arthritis,ulcerativecolitisandHodgkinsdisease.Chronicinfectivedisorders,suchasTBorbronchiectasis,canalso
causeit.Thisissecondaryamyloidosis.
Amyloidosiscanalsobeprimary,causedbyabnormalBcellsthatproduceabnormallightchainsorlightchain
fragments.Thesecombinetoformamyloid.
Familialamyloid,alsoknownastransthyretinamyloidosis,isautosomaldominantandcausedbyamutationofthe
TTRgeneandmainlymanifestswithneurologicalproblems.
Pompedisease(OptionA)isincorrect.Ingeneralahypertrophiccardiomyopathydevelops.Pompediseaseis
characterisedbycardiomyopathy,rapidonsetofmusclehypotonia,weakness,glossomegaly,normalcerebral
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development.Deathiscommoninthefirstyearoflife.
Endocardialfibroelastosis(OptionC)isincorrect.Arestrictivecardiomyopathydevelopsfromendocardialfibroelastosis,
whichistypifiedbyacollagenlayerintheendocardium,especiallytheleftventricle.Mostinfantswithisolateddisease
presentbyage3monthswithheartfailure.
Carnitinedeficiency(OptionD)isincorrect.Ametaboliccardiomyopathydevelopswithcarnitinedeficiency.
Acutecoxsackievirusinfection(OptionE)isincorrect.Aviralmyocarditisispossibleaftercoxsackievirusinfection,but
acardiomyopathyisusuallyuncommon.
41900
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Question217of295
Apatientwithacuteinferiorwallmyocardialinfarction(MI)developsshock2haftersuccessfulprimaryPCItoopenan
occludedrightcoronaryartery.HRis110andtheBPis80/50.Therehasbeennourineoutputforthelasthour.
Auscultationdoesnotrevealanymurmursandthechestisclear.
WhichoneofthefollowingcomplicationsofhisMIismostlikelytobethecause?
A Atrialfibrillation
B Cardiacrupture
C Interventricularseptalperforation
D Papillarymusclerupture
E Rightventricularinfarction
Explanation
TheanswerisRightventricularinfarction
HypovolaemicshocksecondarytoRVinfarction
Rightventricularinfarctionoccursinonethirdofcasesofinferiorwallmyocardialinfarction.AcutelossofRV
functionleadstopoolingofbloodintherightventricle,withconsequentdecreasedpreloadintheleftventricle
resultinginhypovolaemicshock.Ahighindexofsuspicionisrequiredforallinferiorinfarctionssincethereareno
murmursandnopulmonaryoedemathiswouldfitwiththeclinicalscenariopresentedhereandthereforeDisthe
correctanswer.PatientsshouldbetreatedwithaggressiveIVfluidsincreasingvenousreturntotheRVwill
promotepreloadfortheLV.TreatingtheinferiorinfarctiontolimittheRVinfarctioniscritical.
Atrialfibrillation(OptionA)isincorrect.Atrialfibrillationisnotedin10%ofpatientswithmyocardialinfarction,but
doesnottypicallyleadtoshock.
Cardiacrupture(OptionB)isincorrect.Cardiacruptureismorelikelytooccurafteracutemyocardialinfarctionhas
completedandwillmorelikelypresentafterseveraldays.Patientstypicallyundergocardiacarrestwithinminutesafter
rupture.ThesefeaturesmakeitlesslikelyforAtobethecorrectanswerforthisscenario.
Interventricularseptalperforation(OptionC)Interventricularseptalperforation(creatinganacuteVSD)ismorelikelyin
anteriormyocardialinfarctionandthesignificantlefttorightshuntwouldleadtoacutepulmonaryoedemaaswellasa
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loudsystolicmurmur.
Papillarymusclerupture(OptionD)isincorrect.Papillarymusclerupturecanalsooccurininferiormyocardialinfarction
particularlythoseaffectingthecircumflexartery,sincethisvesselperfusesthepapillarymuscles.Whenthisoccurs,
patientsdeveloptorrentialacuteischaemicmitralregurgitation.Theregurgitantvolumeistypicallyveryhighandacute
pulmonaryoedemafollowsrapidly.Thepatientwouldhavealoudpansystolicmurmurandhavecracklesonauscultation
andthereforeCwouldnotbethecorrectanswerinthisscenario.
41952
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Question218of295
A58yearoldwomansuffersacardiacarrestwhileontheward.ArhythmstripshowsVF.
Whatisthestrength(injoules)recommendedforthemonophasicshockusedfordefibrillation?
A 50J
B 100J
C 200J
D 300J
E 360J
Explanation
Theansweris360J
TheResuscitationCouncil(UK)recommendsthattheinitialenergylevelforthefirstshockwithamonophasic
defibrillatoris360J.
Biphasicdefibrillationismoreeffectivethatmonophasicdefibrillation,hencelowerenergiesintherangeof150200
Jarerecommendedforthefirstshock.Themajorityofdefibrillatorsinmodernclinicalpracticearebiphasic.
Cardiacarrest
Aetiology
Threequartersofcardiacarrestsareduetoventricularfibrillation
Onlyasmallproportioncanbeattributedtopulselesselectricalactivity(PEA)therestareduetoasystole
PEAmayhaveapotentiallyreversiblecause:
hypovolaemia
hypoxia
hyperkalaemia
hypokalaemia
hypothermia
tensionpneumothorax
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tamponade
toxicityduetodrugs
thromboembolism
Defibrillation
Defibrillationisusedtoconvertventricularfibrillationtosinusrhythm
TheResuscitationCouncil(UK)recommendsaninitial360Jshockforamonophasicdefibrillatorand150200J
forabiphasicshock
50J(OptionA)isincorrect.TheResuscitationCouncil(UK)recommendsthattheinitialenergylevelforthefirstshock
withamonophasicdefibrillatoris360J.
100J(OptionB)isincorrect.TheResuscitationCouncil(UK)recommendsthattheinitialenergylevelforthefirstshock
withamonophasicdefibrillatoris360J.
200J(OptionC)isincorrect.TheResuscitationCouncil(UK)recommendsthattheinitialenergylevelforthefirstshock
withamonophasicdefibrillatoris360J.
300J(OptionD)isincorrect.TheResuscitationCouncil(UK)recommendsthattheinitialenergylevelforthefirstshock
withamonophasicdefibrillatoris360J.
41877
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Question219of295
A69yearoldmanpresentstothelocalteachinghospitalduringthenightwitha30minshistoryofchestpain.ECG
showsaninferiorwallinfarctionwithSTelevationof3mm.Thereisnohistoryofdiabetesmellitus,injuryorprevious
surgery.Bloodpressureis132/70mmHgwithapulseof58bpm.
Whichoneofthefollowingtreatmentswouldbemostappropriate?
A Abciximabbolusdoseandinfusionfollowedbyangioplasty
B Aspirin,clopidogrelandprimaryangioplasty
C Aspirin,fondaparinuxandTPAfollowedbyfacilitatedangioplasty
D Aspirin,prasugrelandfondaparinux
E Metoprolol,highintensitystatinandspironolactone
Explanation
TheanswerisAspirin,clopidogrelandprimaryangioplasty
Treatmentofmyocardialinfarction(MI)
InSTelevationMI(STEMI),patientswithpersistentSTelevationshouldbeconsideredforreperfusiontherapy
(thrombolysisorprimaryPCI).
Themoderntreatmentofmyocardialinfarctionisprimaryangioplastyandshouldbeconsideredfirstline.All
patientsshouldbegivenaspirin300mg,aloadingdoseofasecondantiplatelet(typicallyclopidogrel,butprasugrel
andticagrelorarealternativeswithincreasinguse).Heparinswillbegivenduringtheangioplastyprocedureandso
shouldbeavoidedpreprocedureasthebleedingriskisaccentuatedwhenusingafemoralarteryapproach.Only
optionAfitsthisapproachmostcloselyandthereforeistherightanswer.
PPCIandtimings
Primaryangioplastyshouldbeperformedwithin2hofarrivalatthehospital(ideallywithin90minthisisthe
doortoballoontime).Ifthiscannothappen,thenthrombolysisshouldbeconsidered.
ThrombolyticsshouldalsobeconsiderediftherewillbelongdelaystotransferapatienttothePPCIcentre.
RescuePPCIshouldbeperformedifthepatientfailstohavereductioninSTsegmentelevationby50%.
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Manylargetrialshaveshownthatthrombolysiswithin12hreducestheextentofventriculardamageandthe
mortalityrate.
After12h,thebenefitsofrevascularisationfallconsiderablybutitistypicallystillperformedattheearliest
opportunity.
Thrombolytics
Althoughthrombolyticsarelesscommonlyused,itisimportanttobeawareofthemastheycanstillfeaturein
examinationquestions.
Tissueplasminogenactivator(TPA)achieveshigherreperfusionratesthanstreptokinase,butmaybe
associatedwithahigherriskofbleedingstrokethanPPCI.
TPAtendstobegiveninpreferencetostreptokinaseinpatientsunder50yearsofagewithanteriorwall
myocardialinfarctionswherethebloodpressureislow(systolic<100mmHg),andinthosepatientswho
havepreviouslyreceivedstreptokinase.
TPAalsoappearstobemoreeffectivethanstreptokinaseifitisadministeredwithin4hoftheonsetofchest
pain.
Abciximabbolusdoseandinfusionfollowedbyangioplasty(OptionA)isincorrect.Thisoptionmentionsabciximab,
whichisanintravenousGPIIbIIIaantagonistthesedrugsarepowerfulantiplateletswhichworkwithnearimmediate
effect.However,theydramaticallyincreasebleeding.Inthepasttheywereusedasaninfusiontobridgeunstablepatients
withNSTEMIwhileawaitingangioplasty.Inthemodernera,theyarepredominantlyusedduringprimaryangioplastyin
patientswithhighriskanatomyandthosewithahighthrombusburden.Sinceneitherisapplicableinthissituation,itis
notthecorrectanswer.
Aspirin,fondaparinuxandTPAfollowedbyfacilitatedangioplasty(OptionC)isincorrect.SincePPCIispreferred,this
wouldnotbethebestanswer.
Aspirin,prasugrelandfondaparinux(OptionD)isincorrect.ThisdoesnotmentionPPCIandthereforeisnottheright
answer.
Metoprolol,highintensitystatinandspironolactone(OptionE)isincorrect.Thisapproachsuggestsmedicationsthatmay
wellneedtobeused,butthefirstpriorityistorevascularisetheoccludedvesseltheywouldbestartedafterPPCI.
41954
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Question220of295
WhichoneofthefollowingisthecommonestcardiovascularabnormalityseeninanadultpatientwithMarfansyndrome?
A Aorticregurgitation
B Aorticrootdilatation
C Mitralregurgitation
D Mitralannularcalcification
E Aorticdissection
Explanation
TheanswerisAorticrootdilatation
Marfansyndromeisaconnectivetissuedisorderthatisinheritedasanautosomaldominanttrait.Thereis
considerablevariationinitsclinicalmanifestations.AlloftheoptionslistedinthequestioncouldhappeninMarfan
syndrome,themostcommonfeaturehoweverisaorticrootdilatation:thisoccursbecausethefibrillengenedefect
meansthearterialwallmediaisabnormalandweakened.Theaorticrootisexposedtothegreatestpressure,making
itliabletorootdilatationandformationofafusiformaorticaneurysm.
Aorticregurgitation(OptionA)isincorrect.Onceaorticrootdilatationoccurs,therecanbefailureofcoaptationofvalve
leaflets,leadingtoaorticregurgitation,thisisnothoweverthemostcommoncardiovascularabnormalityseen.
Mitralregurgitation(OptionC)isincorrect.Mitralregurgitationcanresultfrommitralvalveprolapse,dilatationofa
mitralvalveannulusormitralannularcalcificationmitralvalveprolapseisthesecondmostfrequentfeatureinMarfans.
Mitralannularcalcification(OptionD)isincorrect.Thisisnotthemostcommonlyseencardiovascularabnormality.
Aorticdissection(OptionE)isincorrect.Thisisnotthemostcommonlyseencardiovascularabnormality
41854
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Question221of295
A70yearoldwomanisadmittedwithchestpainandbreathlessnessof12hoursduration.Shehasapasthistoryof
hypertensioncontrolledwithramipril,andasthmaforwhichshetakesinhalers.Onexamination,herheartrateis170bpm
andherbloodpressureis125/72mmHg.ECGshowsatrialfibrillation.Thereismildwheezethroughoutherchest.
Whatisthenextstepinhermanagement?
A Administrationofpropranolol
B Administrationofsalbutamol
C Asynchronouscardioversion
D Administrationofwarfarin
E Immediateheparinisation
Explanation
TheanswerisImmediateheparinisation
Thisscenarioisabouttheacutetreatmentofatrialfibrillation(AF)witharapidventricularresponse(socalledfast
AF).ThedrugmanagementoffastAFwillaimtoachieverapidheartcontrolusingblockersorcalciumchannel
antagonists,oraimforcardioversiontosinusrhythmusinganantiarrhythmicsuchasamiodarone.Whileitis
appropriatetostartpatientswithAFonwarfarin,inthefirstinstance,heparinshouldbegiven.Warfarinhasapro
coagulanteffectandshouldbeideallystartedwithheparincoveruntilitreachesatherapeuticlevel.Intheacute
situation,heparinshouldbegivensincethereisatheoreticalriskofembolisationfromclotsformedduringAFthis
isespeciallytrueifsinusrhythmmayreoccur,whichmayhappenwitheitherrateorrhythmcontrolstrategy.
Thereforeheparinisationismoreappropriatehere.
Atrialfibrillation
Highriskpatientsincludethosewith
aheartrategreaterthan150bpm
chestpainoanunstablecondition
shock
Treatment
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TheappropriatetreatmentforAFisdeterminedbythepatientsrelativeriskfromthearrhythmia.
Thesepatientsrequireurgenttreatment.
Immediateheparinisation,toreducetheriskofsystemicembolisation,andattemptedcardioversionwith
synchronisedDCshockshouldbecarriedoutfirst.
Warfarintreatmentisindicatedintheelderlyandthosewithheartdisease,andwherethedurationofAFislonger
than48hourspriortoconsideringcardioversion.
Youngpatientswithloneatrialfibrillationintheabsenceofheartdiseasemaynotneedanticoagulationinthe
longerterm,butshouldhaveanticoagulationwhenbeingworkedupforelectiveDCcardioversion.
Ingeneral,sinceAFoftenrecursandisoftensilent,longertermanticoagulationdecisionswillbebaseduponthe
CHA2DS2VAScscore.
CHA2DS2VAScscore
Score1pointforcardiacfailure,hypertension,diabetes,vasculardisease,age6574,female
Score2pointsforage75,previousstroke,TIAorthromboembolicevent
Maximumscoreis9becauseagecancontribute0,1or2points
0 0 Aspirinornil(preferred)
1 1.3 Aspirinorwarfarin
2 2.2 warfarin
3 3.2 warfarin
4 4.0 warfarin
5 6.7 warfarin
6 9.8 warfarin
7 9.6 warfarin
8 6.7 warfarin
9 15.2 warfarin
Administrationofpropranolol(OptionA)isincorrect.Propranololisablockerandcanbegivenorallyorinintravenous
form.However,inthiscase,thepatienthasasthmaandtheuseofanonselectiveblockerrisksthepossibilityof
bronchospasm.
Administrationofsalbutamol(OptionB)isincorrect.Inthisscenario,theAFisanurgentprioritysalbutamolwilllikely
alsoincreaseherheartrate.
Asynchronouscardioversion(OptionC)isincorrect.DCcardioversionshouldalwaysbeconsideredfor
haemodynamicallyunstablepatients.However,notonlyisthispatientstable,buttheoptionstatesasynchronous,which
wouldriskgivingtheshockduringaTwaveRonTphenomenawilltriggerventricularfibrillation.Onlyshocksin
cardiacarrestforventricularfibrillationshouldbeasynchronousallothershocksshouldbesynchronous.
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Administrationofwarfarin(OptionD)isincorrect.Asdescribedheparinisastionismoreappropriatethanwarfarinisation
inthissituation.
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Question222of295
Leftbundlebranchblockisassociatedwithwhichoneofthefollowingconditions?
A Ischaemicheartdisease
B Mitralstenosis
C Pericarditis
D Pulmonaryembolism
E Tricuspidstenosis
Explanation
Bundlebranchblocks
Mitralstenosis,tricuspidstenosisandsecondarypulmonaryhypertensionduetopulmonaryembolismare
associatedwithrightventricularstrainandhypertrophywithpartialorcompleterightbundlebranchblock
Pericarditisisnotassociatedwithbundlebranchblock.
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Question223of295
Apatientwithanginaisadmittedforcardiaccatheterisation.Thereisasuspicionthatshemaybesufferingfrom
hyperthyroidism,andthisisconfirmedbyasuppressedTSH.
Whichinvestigationismostpredictiveastowhethertheuseofcontrastmediamayworsenanyunderlyingthyroid
condition?
A Thyroidradionuclideisotopescan
B TSHlevels
C T4levels
D MeasurementofTPOantibodies
E Ultrasoundscan
Explanation
TheanswerisThyroidradionuclideisotopescan
ThispatienthashyperthyroidismbasedonasuppressedTSH.ThetwocommoncausesareGravesdisease(cross
reactionofantibodieswiththeTSHreceptor)andatoxicmultinodulargoiter(excessproductionfromfunctionally
autonomousthryroidnodules).
Adoseofnonradioactiveiodine(asiscontainedincontrast)will,asthequestionalludesto,havevaryingeffectson
theirproductionofthethyroidhormones.
InpatientswithGravesdiseasetheWolffChaikoffeffectwilldominate.Thisisthesuppressionofthyroidhormone
productioninpartduetoatransientinhibitionofthyroidperoxidasewithrisingintrathyroidaliodine.
Inpatientswithautonomousthyroidnodules,however,hyperthyroidismwilldominatesincethenodulesdonot
respondtonormalhormonalautoregulatorymechanisms.Theywillcontinuetoproduceexcessivethyroidhormone.
Outofalltheoptions,athyroidradionuclideisotopescanwilldifferentiatebetweenthesetwodiseases.Graves
diseasewillshowuniformlyelevatediodineuptake.Toxicmultinodulargoiterwillshowmultiplefociofvariably
increasediodineuptake.
Hyperthyroidismandcardiaccatheterisation
Cardiaccatheterisationrequirestheuseofaniodinecontainingcontrast.
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Thismayworsenhyperthyroidismcausedbytoxicmultinodulargoitre,whereasitmayimprovethesymptomsin
patientswithGravesdisease(WolffChaikoffeffect).
Themostreliablediagnosticmethodisaradionuclide(99Tcm,123Ior131I)scanofthethyroid,whichwill
distinguishthediffuse,highuptakeofGravesdiseasefromnodularthyroiddisease.
Ifatoxicmultinodulargoitreortoxicadenomaisdetected,thepatientshouldreceiveanantithyroiddrugbefore
undergoingcatheterisation.
Theantithyroidmedicationmustbecontinuedforatleast2weeksaftertheprocedure.
TSHlevels(OptionB)isincorrect.TSHlevelswillbesuppressedinbothGravesandtoxicmultinodulargoitre.
T4levels(OptionC)isincorrect.T4levelswilltheraisedinbothGravesandtoxicmultinodulargoiter.
MeasurementofTPOantibodies(OptionD)isincorrect.TPOantibodiescanbepresentinbothGravesandHashimotos
thyroiditis(whichhasahyperthyroidphasebeforethepatientbecomeshypothyroid),soagainisnonconclusive.
Ultrasoundscan(OptionE)isincorrect.Ultrasoundcanbeusedtoshowthepresenceofasolitarylesionoramultinodular
goitre,butwillnotprovideadefinitivediagnosis.
41907
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Question224of295
Apatienthasbroadcomplextachycardia.
Thepresenceofwhichfollowingfeatureincreasesthelikelihoodthattherhythmisaventriculartachycardiaasopposedto
asupraventriculartachycardiawithabberantconduction?
A Absenceofcaptureorfusionbeats
B TheQRScomplexshowsanrsRpattern
C AnRtoSinterval<100msinallprecordialleads
D PwaveprecedingwideQRScomplex
E AbsenceofanRScomplexinallprecordialleads
Explanation
TheanswerisAbsenceofanRScomplexinallprecordialleads
TheabsenceofanRScomplex,i.e.,alltheleadsareconcordant,increasesthelikelihoodthattherhythmis
ventriculartachycardia.
Alltheotheroptionsincreasethelikelihoodthattherhythmisasupraventriculartachycardiacwithaberrant
conduction.
Diagnosisofventriculartachycardia
SupraventriculartachycardiawithbundlebranchblockmayresembleventriculartachycardiaontheECG
Eightypercentofallbroadcomplextachycardiasaresecondarytoventriculartachycardiaandtheproportionis
evenhigherinpatientswithstructuralheartdisease.
BeverywaryofdiagnosinganSVTwithaberrancyinapatientahistoryofischaemicheartdisease.
Inallcasesofdoubt,therhythmshouldbetreatedasaventriculartachycardia.
Ifthepatientisunstable,eg.Bloodpressureislow,emergentelectricalcardioversionshouldbeperformed.
ECGdiagnosisofVT
TheECGshowsarapidventricularrhythmwithbroad(often0.14sormore)abnormalQRScomplexes
AVdissociationmayresultinvisiblePwaves
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Capturebeats(intermittentnarrowQRScomplexowingtonormalventricularactivationviatheAVnodeand
conductingsystem)andfusionbeats(intermediatebetweenventriculartachycardiabeatandcapturebeat)areseen
Ventriculartachycardiaismorelikelythansupraventriculartachycardiawithbundlebranchblockwhenthereis
averybroadQRS(>0.14seconds)
atrioventriculardissociation
abifiduprightQRSwithatallerfirstpeakinV1
adeepSwaveinV6
aconcordant(samepolarity)QRSdirectioninallchestleads(V1V6)
Absenceofcaptureorfusionbeats(OptionA)isincorrect.Capturebeatsoccurwhentheatriacapturestheventricleto
producealessabnormalQRSduringVT(thatis,apwavefromtheatriamanagestoactivatethehispukinjesystem
beforetheabnormalVTfocus).Fusionbeatsoccurwhenasinusandventricularbeatcoincide,producingafusedQRS
duringVTthesebeatslooklikeacrossbetweenthepatientsnormalQRSandtheVTbeats.Hence,theirabsencemakes
thisoptionincorrect.
TheQRScomplexshowsanrsRpattern(OptionB)isincorrect.RightbundlebranchblocktypicallyproducesarsR
pattern(withtherightRistaller).
AnRtoSinterval<100msinallprecordialleads(OptionC)isincorrect.BrugadassignisanRtoSinterval>100ms
andmakesVTmorelikely.
PwaveprecedingwideQRScomplex(OptionD)isincorrect.InVTthereisatrioventriculardissociation,hencethe
presenceofaPwaveprecedingawideQRScomplex,isincorrect.
41903
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Question225of295
Anobese50yearoldwomansuddenlydevelopsdyspnoeaandhypotension3.5daysafterundergoingatotalabdominal
hysterectomy.Thereismildjugularvenousdistension.Thelungfieldsareclear.ECGshowstachycardiawitharight
bundlebranchblockandminorSTsegmentchanges.
Whatisthemostlikelydiagnosis?
A Acutemyocardialinfarction
B Pulmonaryembolism
C Aspirationpneumonia
D Aorticdissection
E Pneumothorax
Explanation
TheanswerisPulmonaryembolism
ThispatienthasaclassicalhistoryofPEafterarecentmajorpelvicoperation.Pulmonaryembolismpresentswitha
raisedjugularvenouspressure(JVP)andrightbundlebranchblockduetoacuterightheartimpairmenttheRV
cannotpumpagainstthelargeclotinthepulmonarycirculation.
Acutemyocardialinfarction(OptionA)isincorrect.Ifamyocardialinfarction(MI)iscausinghypotension,thenitis
likelytobecausingcardiogenicshock,whichismorelikelytohavegrossSTchangesontheECG.ThereforeacuteMIis
lesslikelythanaPE.
Aspirationpneumonia(OptionC)isincorrect.Theclearlungfieldsonauscultationprecludesadiagnosisofpneumonia.
Aorticdissection(OptionD)isincorrect.AorticdissectionwouldcauseaMIoraorticregurgitationbeforecausing
respiratorydistressmakingthislesslikelythanthediagnosisofPE.
Pneumothorax(OptionE)isincorrect.Theclearlungfieldsonauscultationmakeapneumothoraxlesslikely.
41960
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Question226of295
A78yearoldwomanisadmittedbyambulancefromhome.Shewasfoundlyingonthefloorbyherhomehelpafter
sufferingafall.Shehasahistoryofhypertensionmanagedwithramipril10mgpodaily.Onexaminationhertemperature
is30.0C,andherBPis100/50mmHg,withapulseof52bpm.Shehasafracturedleftneckoffemur.Clinicalresultsare
giveninthetablebelow:
Hb 14.5g/dl
WCC 4.5109/l
PLT 192109/l
Na+ 143mmol/l
K+ 5.3mmol/l
Creatinine 195mol/l
WhichoneofthefollowingECGfeaturesismostcharacteristicofmoderatetoseverehypothermia?
A LongQTinterval
B ShortPRinterval
C Seconddegreeheartblock
D Completeheartblock
E Jwaves
Explanation
Moderatetoseverehypothermia
Althoughvaryingdegreesofheartblockmaybeseeninassociationwithhypothermia,Jwavesaresaidtobemost
characteristicofmoderatetoseverehypothermia
Jwavesarebestseenintheleftchestleadsandaredescribedasadomeorhumpintheterminalportionofthe
QRScomplex
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ThesizeoftheJwaveiscorrelatedwiththedegreeofhypothermia
Slowatrialfibrillationmayalsobeseenascoretemperaturefalls
Deathfromventriculararrhythmiasiscommoninmoderatetoseverehypothermia
18563
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Question227of295
A72yearoldmancomestotheclinicforreview.Hereportsoccasionalchesttightnessoverthepastyearwhenhewalks
hisdogsonacoldday,orsometimeswhenhewalksupaverysteephillattheendofhis4milehike.Thepainiscentral,
pressinginnature,andrelievedwhenherestsfor23minutes.Hesmokes5cigarettesperday,andhasahistoryofmild
COPDforwhichhetakesaSalbutamolinhaler.OthermedicationincludesIndapamideforhypertensionandAspirin.
ExaminationrevealsaBPof143/82mmHgpulseis84/minandregular.Hischestisclear.
Investigations:
Hb 13.1g/dl
WCC 9.2x109/l
PLT 203x109/l
Na+ 137mmol/l
K+ 4.3mmol/l
Creatinine 100micromol/l
Glucose 5.4mmol/l
Cholesterol 5.2mmol/l
12leadECG Normalsinusrhythm
CXR Nosignsofheartfailure,nofocallesions
Whichofthefollowingisthemostappropriatenextstepwithrespecttohischestpain?
A Referforangiography
B Referforstressechocardiography
C Referforexercisetest
D StartBisoprolol
E StartRamipril
Explanation
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Explanation
TheanswerisStartBisoprolol
Inthissituation,thelikelihoodofadiagnosisofanginais>90%,accordingtoNICEguidance.Assuch,inapatientwith
chronic,stablesymptomsoverthepastyear,treatmentwithanagentsuchasBisoprololisthemostappropriatenextstep.
Ifthisworsenshisshortnessofbreaththenthiscanbealteredtoacalciumchannelantagonist.Ifhedevelopsunstable
diseasewithworseningchestpainthenideallyheshouldbereferredforangiography.NICEguidancedoesnot
recommendtheuseofexercisetestinginthissituation.
http://www.nice.org.uk/guidance/cg95/chapter/1Guidance#peoplepresentingwithstablechestpain
(http://www.nice.org.uk/guidance/cg95/chapter/1Guidance#peoplepresentingwithstablechestpain)
40230
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Question228of295
A35yearoldwomanofAfricanoriginpresentswitha4monthhistoryofincreasingswellingoverherfeetand
abdominaldistension.Shehasnohistoryofcough,orthopnoeaorbreathlessnessonexertion.Herheartrateis98bpm:
irregularlyirregular.HerJVPismarkedlyraisedandshehaspittinglowerlimboedema.Theheartsoundsaresoft,and
therearenoaudiblemurmurs.Abdominalexaminationrevealshepatomegalyalongwithascites.ChestXrayrevealsa
normalcardiacsizeandclearlungfields.AlateralXrayshowscalcificationaroundtheheartborder.Urinalysisisnormal.
HerECGshowsalowQRSvoltageandlateralTwavechanges.
Whatisthelikelydiagnosis?
A Dilatedcardiomyopathy
B Cirrhosisoftheliver
C Constrictivepericarditis
D Restrictivecardiomyopathy
E Hypertrophiccardiomyopathy
Explanation
TheanswerisConstrictivePericarditis
Toanswerthequestionyoumustrecognisethedifferentclinicalpicturesofthedifferentcardiomyopathies.Inthis
case,allthefeaturesareconsistentwithaconstrictivepericarditisdescribedindetailbelow.
Constrictivepericarditis
Diagnosis
ThispatienthassignsofsevererightheartfailurebutthechestXrayrevealsanormalheartsize
Thepossibilitiesareconstrictivepericarditisandrestrictivecardiomyopathy
Thepresenceofcalcificationaroundtheheartfavoursconstrictivepericarditis
Othernotes
Causesofrestrictivecardiomyopathyincludecardiacamyloidosis,haemachromatosis,endomyocardialfibrosis,
systemicsclerosis,carcinoidsyndromeandmalignancy
Cardiacamyloidosisisusuallyassociatedwithmyeloma
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Itismorecommoninmalesintheirsixthorseventhdecades
Dilatedcardiomyopathy(OptionA)isincorrect.Indilatedcardiomyopathies,decompensatedpatientstypicallyhavesigns
ofleftheartfailurewithpulmonaryoedemainadditiontosignsofrightheartfailure(peripheraloedemaandraisedJVP).
ThereforethechestXraywouldnotbeclearandthelungswouldrevealcoarsecrepitations.
Cirrhosisoftheliver(OptionB)isincorrect.Incirrhosisoftheliverpatientstypicallyhavesignsofsignificantascitesand
peripheraloedema.However,thisdiagnosisdoesnotexplainthecalcificationoftheleftheartborder.
Restrictivecardiomyopathy(OptionD)isincorrect.Inrestrictivecardiomyopathy,thekeypathologyisinthemuscleof
theheart:infiltrationoftheheartbyproteins,suchasamyloid,causespoorsystolicanddiastolicfunction.Clinicalsigns
canbedifficulttodistinguishfromconstrictionhowever,thecalcificationofthepericardiumstronglysuggests
constriction.
Hypertrophiccardiomyopathy(OptionE)isincorrect.Inhypertrophiccardiomyopathy,thecardiacmuscleissignificantly
hypertrophiedwithaforcefulapexbeat.TheECGwilldemonstratelargeQRScomplexesfromleftventricular
hypertrophytherecanbeQwavesandTwaveinversiondespitenormalcoronaryarteries.
41853
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Question229of295
A30yearoldwomanwithaprevioushistoryofdeepveinthrombosisisexpectingherfirstchild.
Duringwhichphaseofherpregnancyandpuerperiumdoesshehavethegreatestriskofvenousthrombosis?
A Firsttrimester
B Secondtrimester
C Thirdtrimester
D Duringdelivery
E First6weeksafterdelivery
Explanation
TheanswerisFirst6weeksafterdelivery
Deepveinthrombosisinpregnancy
Thromboemboliccomplications
Thereisanincreaseinthromboemboliccomplicationsinthemotherinthefirst6weeksafterdeliverybecauseof
thehypercoagulabilitythatexistspostpartum
Overallpregnancyandpeurperiumincreasestheriskofvenousthromboembolismfourtofivefoldoverthat
presentinthenonpregnantstate.By4monthsafterdelivery,theriskisbackdowntothewomansnormalbaseline
riskofclots
Management
Anticoagulantsmaybenecessaryduringpregnancytopreventorcontrolthefollowing
venousthrombosis
pulmonaryembolism
rheumaticmitralvalvedisease
prostheticheartvalves
peripartumcardiomyopathy
primarypulmonaryhypertension
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Eisenmengersyndrome
Firsttrimester(OptionA)isincorrect.Thegreatestriskofthromboemboliccomplicationsinthemotherisinthefirst6
weeksafterdeliverybecauseofthehypercoagulabilitythatexistspostpartum.
Secondtrimester(OptionB)isincorrect.Thegreatestriskofthromboemboliccomplicationsinthemotherisinthefirst6
weeksafterdeliverybecauseofthehypercoagulabilitythatexistspostpartum.
Thirdtrimester(OptionC)isincorrect.Thegreatestriskofthromboemboliccomplicationsinthemotherisinthefirst6
weeksafterdeliverybecauseofthehypercoagulabilitythatexistspostpartum.
Duringdelivery(OptionD)isincorrect.Thegreatestriskofthromboemboliccomplicationsinthemotherisinthefirst6
weeksafterdeliverybecauseofthehypercoagulabilitythatexistspostpartum.
41892
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Question230of295
A68yearoldmanisadmittedwithsyncope.Heisknowntohaveischaemiccardiomyopathy.Hismedicationsinclude:
aspirin75mgod,frusemide80mgbdandlisinopril10mgod.AninitialECGshowssinusbradycardia(50bpm)and
RBBB.Resultsofbloodtestsareasfollows:sodium,134mmol/litrepotassium,3.5mmol/litrecreatinine124mol/litre.
HehasrecurrentsyncopalepisodesontheCCU,wheremonitoringshowsepisodesofnonsustainedtorsadesdepointes
(polymorphicVT).Whichoneofthefollowingwouldbeyourinitiallineoftreatment?
A DCcardioversion
B Intravenousamiodarone
C Intravenousmagnesium
D Oralmetoprolol
E Temporarypacing
Explanation
QTprolongation
Torsadesdepointes(polymorphicVTwithQRScomplexesofdifferentamplitudetwistingaroundtheisoelectric
line)occursinpatientswithaprolongedQTinterval
Predisposition
AnycauseofQTprolongationcanpredisposetothearrhythmia
Theseinclude
congenital(theJervellLangeNeilsenorRomanoWardsyndromes)
withQRScomplexesofdifferentamplitude
metabolic(hypocalcaemia,hypomagnesaemiaorhypokalaemia)
drugs(egamiodarone,tricyclicantidepressants,phenothiazines)
ischaemicheartdisease
mitralvalveprolapsed
Thearrhythmiaoftenoccursinthecontextofbradycardia
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Treatment
Thekeyhereisthatamiodaronemayexacerbatethesituation
Intravenousmagnesium(eveniftheserummagnesiumconcentrationisnormal)isthefirstlinetherapy
Temporarypacingathigherrateswithorwithoutblockersisthenextlineoftherapy
DCshockwouldnotbehelpfulsinceepisodesarenonsustained
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Question231of295
A20weekspregnantwomanwithahistoryofasthma,whichoncerequiredITUadmission,isnotedtohaveconsistent
bloodpressurereadingsover170/95mmHg.
Whichoneofthefollowingantihypertensiveswouldyouinitiateforthispatient?
A Nifedipine
B Diltiazem
C Bendrofluazide
D Enalapril
E Losartan
Explanation
TheanswerisNifedipine
NICEhaveproducedclearguidelines(CG107)aboutthemanagementofhypertensioninpregnancyandrecommend
specifictherapies.Theirrecommendedfirstlineagentisorallabetalol.This,however,iscontraindicatedinthis
circumstanceduetothesignificantasthma.Thetwosuggestedalternativesarenifedipineandmethyldopa(which
againwouldberelativelycontraindicatedwithasthma).
Diltiazem(OptionB)isincorrect.Diltiazemisnotrecommendedbytheguidelines.
Bendrofluazide(OptionC)isincorrect.Bendrofluazideisrelativelycontraindicated.
Enalapril(OptionD)isincorrect.ACEinhibitorsareabsolutelycontraindicated.
Losartan(OptionE)isincorrect.Angiotensinreceptorblockersareabsolutelycontraindicated.
41913
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Question232of295
A48yearoldmanisadmittedwithaprolongedepisodeofchestpainatrest.TheECGshowsSTdepressioninthelateral
leads.HistroponinTleveliselevated.
Whichofthefollowingisthemostappropriatecombinationofdrugsforinitialtreatment?
A Aspirin,ramipril,unfractionatedheparin,diltiazem
B Aspirin,warfarin,lowmolecularweightheparin(LMWH),atenolol
C Aspirin,clopidogrel,LMWH,atenolol
D Aspirin,losartan,unfractionatedheparin,atenolol
E Aspirin,ramipril,LMWH,nicorandil
Explanation
TheanswerisAspirin,clopidogrelLMWH,atenolol
ThemanagementofanonSTelevationmyocardialinfarction(NSTEMI)includestreatmentwithtwoantiplatelet
agents,suchasaspirinandclopidogrelananticoagulant,LMWHandantiischaemictherapy,suchasatenolol.In
lightofthenewantiplatelets,TicagrelororPrasugrelmaybeconsideredinsteadofclopidogrel,whichhaslongbeen
thestandardofcare.
NonSTelevationmyocardialinfarction
Theinitialtreatmentofunstableangina(UA)shouldincludebedrest,antiplatelettherapy,anticoagulationanda
blocker.
Asystematicreviewfoundthataspirinalone(75325mg/d)reducestheriskofdeathandmyocardialinfarctionin
patientswithUA.Alarge,randomised,controltrial(RCT)hasshownthatthecombinationofclopidogrel(75mg/d)
andaspirinissuperiortoaspirinalone.Inthemodernera,Prasugrelhasadvantagesincompositeclinicalendpoints
overclopidogrelinthosepatientsdestinedforinvasivemanagementbutdoeselevatebleeding.Ticagrelorhasan
additionalbenefitinreducingmortalityoverandaboveclopidogrel.
ManyRCTshavefoundthattreatingthosepatientsatriskofUAwithLMWHismoreeffectivethanaspirinalone.
AntiischaemictherapywithablockersuchasmetoprololisrecommendedinNSTEMIdiltiazemorverapamil
canbeusedifblockersarecontraindicated.However,nonratinglimitingcalciumchannelantagonistssuchas
nefidipineandamlodipineareassociatedwithincreasedmortalityduringACSandsoshouldbeavoided.
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PatientspresentingwithNSTEMIshouldbeconsideredforrevascularisation.Thosewhoundergocoronary
angioplastyshouldalsobeconsideredfortreatmentwithanintravenousglycoproteinIIb/IIIainhibitorsuchas
abciximab,tirofibanoreptifibatide.
Aspirin,ramipril,unfractionatedheparin,diltiazem(OptionA)isincorrect.TheadditionofLMWHtoaspirinhasbeen
demonstratedinmultipleRCTs.TheadvantagesofLMWHoverunfractionatedheparinincludeitseaseofadministration
andnoneedformonitoring.
Aspirin,warfarin,LMWH,atenolol(OptionB)isincorrect.Theadditionofwarfarinisnotrecommendedandwould
likelycauseexcessbleeding.
Aspirin,losartan,unfractionatedheparin,atenolol(OptionD)isincorrect.TheadditionofLMWHtoaspirinhasbeen
demonstratedinmultipleRCTs.TheadvantagesofLMWHoverunfractionatedheparinincludeitseaseofadministration
andnoneedformonitoring.
Aspirin,ramipril,LMWH,nicorandil(OptionE)isincorrect.Althoughdiltiazemandverapamilareappropriate
alternativestoblockadeasantiischaemictherapyinNSTEMI,therearenosignificantRCTdatatosupporttheuseof
nicorandil(theforeoptionEisincorrect).TherearedatatosuggestratelimitingcalciumchannelantagonistsinNSTEMI
aresuitableinacutecoronarysyndrome(ACS).However,nonratinglimitingcalciumchannelantagonistssuchas
nefidipineandamlodipineareassociatedwithincreasedmortalityduringACSandsoshouldbeavoided.
41876
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Question233of295
A67yearoldmanattendsthecardiologyclinic.Hehasbeensufferingsomeanginatypechestpainongoingoutinthe
coldairandisworriedthathemighthavecoronaryarterydisease.Thereisapastmedicalhistoryofsmoking20cigarettes
perdayandhypertensionwhichismanagedwithramipril10mgdaily.HisGPhassentanECGwhichappearstoshow
thatheisinleftbundlebranchblock.Whichoneofthefollowingwouldyouexpecttohearonauscultation?
A Loudfirstheartsound,reversedsplittingofthesecondheartsound
B Softfirstheartsound,fixedsplittingofthesecondheartsound
C Softfirstheartsound,reversedsplittingofthesecondheartsound
D Softfirstheartsound,normalsecondheartsound
E Loudfirstheartsound,normalsecondheartsound
Explanation
Auscultationfindingsofleftbundlebranchblock
Leftbundlebranchblockresultsintheleftventricledepolarisingfromcelltocellconductionviatheright
ventricle,ratherthanviathenormalpathway
Thisresultsinreversedsplittingofthesecondheartsound,inotherwordssplitinexpirationandsinglein
inspiration
Additionallythefirstheartsoundtendstobesofterthanusual
Leftbundlebranchblockinthisagegroupismostlikelytobeischaemicinorigin,hencehischestpainalmost
certainlywarrantsfurtherinvestigation,especiallygivenhishistoryofsmokingandhypertension
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Question234of295
A68yearoldman,althoughasymptomaticfromthecardiacviewpoint,hasanejectionsystolicmurmurbestheardinthe
aorticarea.Themurmurradiatestothecarotids.Echocardiographyconfirmssevereaorticstenosiswithagradientof85
mmHgacrossthecalcifiedaorticvalve.
Whatistheriskofsuddencardiacdeathperyearinsuchpatients?
A Lessthan5%
B 69%
C 1025%
D 2550%
E Morethan75%
Explanation
TheanswerisLessthan5%
Thisquestiontacklesawarenessoftheprognosisofasymptomaticsevereaorticstenosis.Thesepatientsaretypically
monitoreduntiltheydevelopsymptoms.Thiscouldonlybedoneiftheriskofdeathwaslow.
Aorticstenosis
Theriskofcardiacdeathinpatientswithsymptomaticandasymptomaticaorticstenosisaccordingtovalvegradient
iscalculatedusingdatafromepidemiologicalstudies.
Developmentandprognosis
Thenaturalhistoryofaorticstenosisinadultsischaracterisedbyalonglatentperiod,duringwhichthereisa
graduallyincreasingobstructionandanincreaseinthepressureloadonthemyocardiumwhilethepatientremains
asymptomatic
Agradientof85mmHgconstitutesaverysevereaorticstenosis
Oncesymptomsappearinpatientswithanunrelievedobstruction,theprognosisispoor
Althoughaorticstenosismayberesponsibleforsuddendeath,thisusuallyoccursinpatientswhohavepreviously
beensymptomatic
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Survivalcurveshaveshownthattheintervalfromtheonsetofsymptomstothetimeofdeathisapproximately2
yearsinpatientswithheartfailure,3yearsinthosewithsyncopeand5yearsinthosewithangina
Incidenceofsuddencardiacdeath
Beforetheadventofsurgery,suddencardiacdeathwasquitecommonincasesofaorticstenosis(in1968,
Campbellreportedthat,outof60patientswithaorticstenosiswhodied,44(73%)ofthedeathsweresudden)
Thereisa69%incidenceofsuddencardiacdeathinasymptomaticchildrenwithaorticstenosis
69%(OptionB)isincorrect.Patientswithaorticstenosisaretypicallymonitoreduntiltheydevelopsymptoms.This
couldonlybedoneiftheriskofdeathwaslow.
1025%(OptionC)isincorrect.Patientswithaorticstenosisaretypicallymonitoreduntiltheydevelopsymptoms.This
couldonlybedoneiftheriskofdeathwaslow.
2550%(OptionD)isincorrect.Patientswithaorticstenosisaretypicallymonitoreduntiltheydevelopsymptoms.This
couldonlybedoneiftheriskofdeathwaslow.
Morethan75%(OptionE)isincorrect.Patientswithaorticstenosisaretypicallymonitoreduntiltheydevelopsymptoms.
Thiscouldonlybedoneiftheriskofdeathwaslow.
41890
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Question235of295
A43yearoldmanpresentswithacutecentralchestpainradiatingtohisback.Heispale,sweatyandlooksextremely
unwell.Theadmittingnursenoticesthathisbloodpressuresappeartobeunequalwhencomparingtheleftandrightarms.
Chestauscultationrevealsaorticregurgitation,andontheECGthecomplexeslooksmall.
Whatdiagnosisfitsbestwiththisclinicalpicture?
A Acutemyocardialinfarction
B Aorticdissection
C Aorticregurgitation
D Pericarditis
E Subacutebacterialendocarditis
Explanation
TheanswerisAorticdissection
Thisisaclassicalpresentationthepainissharpanddescribedastearing.Itcannotbeanyoftheotheroptionsasthe
presentationsareverydifferent.
Aorticdissection
Aorticdissectionmaypresentwith
hypertensionorhypotension
unequalorabsentpulses
aorticregurgitation
neurologicalabnormalitiescausedbyvascularocclusion
Hornersyndromeduetomasseffect
cardiactamponadecausedbydissectionintothepericardialsac
Predisposingfactorsinclude
hypertensionMarfansyndromecongenitalaorticvalveabnormalitiessyphilisinfection
ECGmayshowleftventricularhypertrophy,orsmallcomplexessuggestiveofcardiactamponade
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ChestXraymayshowmediastinalwidening,butanteroposteriorprojectionfilmsoverestimatethewidthof
themediastinumanyway
ManagementoftypeAandtypeBdissections
DissectionsaregenerallyclassifiedintotypeAdissections(involvingtheascendingaorta),andtypeB
dissections(involvingthedescendingaorta)
TypeAdissectionsusuallyrequireimmediatesurgicalintervention,althoughtypeBdissectionsmaybe
managedmedically
TypeAdissectionsshouldbediagnosedandmanagedwithoutanydelayevery1hourafterthedissectionis
associatedwithanadditional10%mortalityrise.EvenoperatedpatientscanhaveastormyITUstaypost
surgery
TypeBdissections,althoughmanagedmedically,arenotbenigntheyrequireintensiveinvasivemonitoring
withaggressivebloodpressurecontrol(aimforlowsystolicpressures,often<100mmHgaccordingtolocal
protocols).Therisksofbowelischaemiaandlossofrenalperfusionareveryhigh
Foruntreatedpatients,themortalityrateissaidtoapproach85%eventreatedpatientsstillhaveamortality
rateapproaching20%
Acutemyocardialinfarction(OptionA)isincorrect.InacuteMIthereshouldnotbeadifferenceinbloodpressures
betweenarmsandthepainshouldnotradiateintotheback.Thepainiscrushingandcentral.
Aorticregurgitation(OptionC)isincorrect.Aorticregurgitationisachronicconditionthattakesyearstodevelopinthe
majorityofcases(unlessacutelyduetoendocarditis).Itshouldcausepainorunequalbloodpressures,butifseveremay
causeawidepulsepressure.
Pericarditis(OptionD)isincorrect.Inpericarditisthepainistypicallysharpandpleuritic(worseoninspiration)and
relievedbyleaningforward.Thereshouldbenohaemodynamiccompromise.Iftherewastamponadeduetoaneffusion
fromthepericarditis,thepaintypicallystopsasthepericardialmembranesareseparatedbytheeffusionandnolonger
rubbing.
Subacutebacterialendocarditis(OptionE)isincorrect.Endocarditiswouldbeexpectedtohavefeverandconstitutional
symptoms.Patientsmayhavesplinterhaemorrhages,Oslersnodes,Janewaylesions,weightlossandnightsweats.There
isnotusuallypain.
42009
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Question236of295
A31yearoldmanpresentswithtransientlossofconsciousnessandpalpitations.ECGconfirmsventriculartachycardia.
Whichoneofthefollowingcannotbeusedsafely?
A Adenosine
B Amiodarone
C DCcardioversion
D Flecainide
E Verapamil
Explanation
TheanswerisVerapamil
Verapamil,atypeIVantiarrhythmic,shouldnotbeusedinVT,andshouldbeavoidedintachycardiasunlessa
supraventricularoriginhasbeenestablished.Itwillrapidlycausehaemodynamiccollapse.
Adenosine(OptionA)isincorrect.Adenosinecanbeusedinparoxysmalsupraventriculartachycardias(SVTs)toreturn
thehearttosinusrhythm.Itisalsoofuseinhelpingtodifferentiatebetweenbroadcomplextachycardiasof
supraventricularandventricularorigin.StablepatientswithVTmaybegivenadenosinetoensurethereisnotSVTwith
abberantconduction.
Amiodarone(OptionB)isincorrect.AmiodaroneisatypeIIIantiarrhythmic.Itisusedinthetreatmentofparoxysmal
SVT,ventriculartachycardia(VT),atrialfibrillationandatrialflutter,andinventricularfibrillationduringcardiacarrests.
Althoughausefulmedication,cautionisrequiredforlongtermuseastherearesideeffectsincludinglungfibrosis,liver
dysfunctionandthyroiddysfunctionwithchronicuse.
DCcardioversion(OptionC)isincorrect.SynchronisedDCcardioversioncanbeusedinVTafteranaesthetisingthe
patient.InpulselessVT,DCcardioversionisusedasanemergencyprocedure.NotethatDCCVcanalsobeusedin
persistentSVT,AForflutter.Considerationofanticoagulationwillneedtobetaken.
Flecainide(OptionD)isincorrect.Flecainide,aclassIcantiarrhythmic,canbeusedsafelyinsymptomaticventricular
arrhythmias.Thisagentshouldbeavoidedinpatientswithknowncoronaryarterydiseaseand/orimpairedleftventricular
functionsinceincreasedmortalitywasnotedintheCASTstudy.
42030
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Question237of295
Youaredesigningastudyforanewagentthatmayreducemyocardialnecrosisaftermyocardialinfarction.Theagentis
specificallythoughttoreduceearlymyonecrosis.Whichoneofthefollowingenzymesismostappropriatetomeasure
earlymyocardialnecrosis?
A GlycogenphosphorylaseisoenzymeBB(GPBB)
B Myoglobin
C Creatininekinase
D Troponin
E Lactatedehydrogenase
Explanation
Enzymemeasurementsinearlymyocardialnecrosis
Glycogenphosphorylase(GP)existsinanumberofisoforms,butGPBBexistsinheartandbraintissue
DuringaperiodofischaemiaGPBBisreleasedandiselevated13haftertheevent
Myoglobinlevelsbecomesignificantlyelevated2hafterischaemia,forCKthelevelmaynotbemarkedly
elevateduntil4hormoreafteraninfarct
LDHisalatemarkerofmyocardialinfarctionwhichremainselevatedforafewdaysafterinfarct
Troponinisthecurrentgoldstandardmarkerformyocardialinfarction,althoughlevelsonlybecomeelevatedafter
6hconventionalpracticeistomeasurelevelsat6and12hafteraperiodofchestpain
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Question238of295
Whichoneofthefollowingisacharacteristicfeatureoftroponin?
A Itisanintegralcomponentofpericardialcells
B Levelsriseimmediatelyorevenpriortotheonsetofchestpainduetomyocardialinfarction
C About30%ofinfarctpatientsshowariseinlevelsat12hoursfromtheonsetofsymptoms
D 1ng/mlisthecutoffabovewhichamyocardialinfarctionisindicated
E Levelsactasaprognosticfactorfollowinganacutecoronarysyndrome
Explanation
TheanswerisLevelsactasaprognosticfactorfollowinganacutecoronarysyndrome
Thetroponincomplexispartofthecardiacmyofibrilandisreleasedinmyocardialdamage,levelsarenotelevated
withisolatedpericarditis.Ifthereismyopericarditis,thentroponinlevelswillberaisedfrommyocardial
inflammation.Intruemyocarditis,troponinlevelswillbedramaticallyhigh.
Levelsriseabout4hoursaftertheonsetofchestpain.Thenewhighsensivitityassaysbegintodetectlevelswithin3
hoursafterthechestpain.
Itisanintegralcomponentofpericardialcells(OptionA)isincorrect.Asdescribedthetroponincomplexispartofthe
cardiacmyofibril.
Levelsriseimmediatelyorevenpriortotheonsetofchestpainduetomyocardialinfarction(OptionB)isincorrect.As
describedlevelsriseabout4hoursaftertheonsetofchestpain.
About30%ofinfarctpatientsshowariseinlevelsat12hoursfromtheonsetofsymptoms(OptionC)isincorrect.
Twelvehoursaftertheonsetofchestpain,allpatientswithmyocardialinfarctionarepositivefortroponin.Arisein
troponinisafundamentalrequirementintheThirdUniversalDefinitionofMyocardialInfarction(2012).
1ng/mlisthecutoffabovewhichamyocardialinfarctionisindicated(OptionD)isincorrect.Alevelof>0.1ng/mlis
consideredasasignificantrise.
41868
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Question239of295
An81yearoldwomanisreferredtocardiologyoutpatientswithahistoryofdizzyepisodesandoneepisodeofsyncope.
Sheisknowntohavelongstandingatrialfibrillation.A24hourtapeconfirmsatrialfibrillation,withratesvaryingfrom
30to140bpm.Thereareseveraldaytimepausesofover3seconds.Sinusnodediseaseappearstobethemostlikely
diagnosis.Sheislistedforapermanentpacemaker.
Whichoneofthefollowingwouldbethemostappropriatedevice?
A DDD
B DDI
C VOO
D VVI
E VDD
Explanation
Useofpacemakersinatrialfibrillation
Definition
Pacemakertypesaredefinedbyaninternationalcode,whichusesthreeormorelettersinasetsequence
Thefirstletterisrelatedtothechamberthatistobepaced:A=atrium,V=ventricle,D=both
Thesecondletterreferstothechamberthatissensed(A,VorD)
Thethirdletterreferstotheresponsetoasensedbeatbythepacemaker:I=inhibits,T=triggerorD=
both(ieeitherinhibitsortriggers)
VOOisafixedoutputsetting(egpacingat60beatsperminuteirrespectiveofintrinsicactivity)theO
assecondandthirdsymbolimpliesthatthechamberisnotsensedandthereforethereisnoresponsetoa
sensedbeat
Afourthletterreferstowhetherornotthepacemakerhasrateadaptiveproperties(R)
Casestudy
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Thiswomanhasatrialfibrillationandassuchthereisnoneedforanatriallead
VVImeansthereisoneleadintheventricle(pacingandsensingtheventricle)
IfthepacemakersensesanintrinsicQRScomplexthenpacingisinhibited(I)
Thismeansthepacemakerwillonlydeliverastimuluswhenthereisasignificantpause
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Question240of295
A58yearoldmanwithmultipledentalproblemspresentstotheEmergencyDepartment.Apartfromanabscessonhis
toe,forwhichhehasbeenreceivingflucloxacillin,hehasbeenrelativelywell.Onexaminationhehassplinter
haemorrhagesandlooksanaemic.Youdetectanaorticsystolicmurmur.Echocardiogramissuggestiveofaorticvalve
endocarditis,andbloodculturesconfirmStreptococcusviridans.Inadditiontoivbenzylpenicillin,whichoneofthe
followingantibioticswouldyouprescribe?
A Ceftriaxone
B Gentamicin
C Azithromycin
D Vancomycin
E Ciprofloxacin
Explanation
Streptococcusviridansendocarditis
Thestandardregimeforsuspectedviridansendocarditiswouldbebenzylpenicillinivtogetherwithgentamicin1
mg/kg/day
Ceftriaxoneisanalternativeinstablepatientsandhastheadvantageofbeinggivenonceperday
Inpatientswhoarepenicillinallergic,vancomycinisaviablealternative
Themostlikelyrouteforhisinfectionisviadentalinfection
AslongasStreptococcusviridansendocarditisisappropriatelymanaged,cureratesapproach98%
18567
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Question241of295
A58yearoldmanishavinghisdrugtherapyreviewedfollowingamyocardialinfarction.
Whichoneofthefollowinghasnoprovenbenefitonmortalityfollowingmyocardialinfarction?
A Atorvastatin
B Isosorbidemononitrate
C Ramipril
D Timolol
E Tirofiban
Explanation
TheanswerisIsosorbidemononitrate
Isosorbidemononitrate,adrugusedtotreatangina,showednobenefitintheISIS4study.
Atorvastatin(OptionA)isincorrect.TheMIRACLstudyshowedthatatorvastatinreducedcardiovasculareventsby17%
whengivenfor3monthspostMI.Highintensityatorvastatinisfavouredaftermyocardialinfarctionastheremaybea
favourableeffectonplaquestabilisationandmorphology.
Ramipril(OptionC)isincorrect.Ramipril(AIREstudy)hasbeenshowntoreducemortalitywhenusedduringorafter
myocardialinfarction.
Timolol(OptionD)isincorrect.Timolol(TIMItrial)hasbeenshowntoreducemortalitywhenusedduringorafter
myocardialinfarction.
Tirofiban(OptionE)isincorrect.TheglycoproteinIIb/IIIaantagonisttirofiban(PRISMPLUSstudy)hasbeenshownto
reducemortalitywhenusedduringoraftermyocardialinfarction.
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Question242of295
Whichoneofthefollowingstatementsbestdescribesprimarypulmonaryhypertension?
A Thefamilialformisinheritedassexlinkedrecessive
B Chronicthromboembolicdiseasecanbeidentifiedin30%ofprimarycases
C Spontaneousremissionistheruleinmorethanhalfthecases
D Cannabisinhalationmayinducesimilardisease
E Theriskforsubacutebacterialendocarditisislowandantibioticprophylaxisisseldomrequired
Explanation
TheanswerisTheriskforsubacutebacterialendocarditisislowandantibioticprophylaxisisseldomrequired
Primarypulmonaryhypertension
Pulmonaryhypertension(PH)isaconditionofelevatedpulmonarybloodpressure,whichexceedsmeanpulmonary
pressuresof25mmHgoninvasivecatheterassessment(notonechobasedestimation).
Clinicalpresentation:
Theonsetofsymptoms(egdyspnoea,syncope,chestpain)isusuallyinsidious.
Otherclinicalfindingsmayinclude
elevatedJVP
RVlift
loudP2
murmursoftricuspidorpulmonaryregurgitation
ascites
hepatomegaly
peripheraloedema
peripheralcyanosis
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Causesofpulmonaryhypertension:
previouslyclassifiedasprimaryorsecondary
primaryPHadiagnosisofexclusionnoclearaetiologythreetimesmorelikelyinwoman
secondaryPHcanbecausedby:
chronicpulmonaryemboli
underlyingcollagenvasculardisease
leftsidedheartdisease
chronicobstructivepulmonarydisease.
Modernclassificationisasfollows:
Group1pulmonaryarterialhypertension(PAHprecapillaryproblemcontainsidiopathicandfamilialPAHalso
associatedPAHwherethePHisassociatedwithconnectivetissuediseasesuchasCRESTsyndrome,portal
hypertension,HIV,drugandtoxinssuchasmethamphetamineandfenfluramine)
Group2leftheartdisease
Group3hypoxiaorlungdisease
Group4thromboemobilicorobstructive
Group5otherdiseasesaffectingthepulmonaryvasculature.
Thefamilialformisinheritedassexlinkedrecessive(OptionA)isincorrect.Thefamilialtypeiscausedbydefectsina
numberofdifferentgenes,themostcommonbeingtheBMPR2gene.OthergenesinvolvedincludeALK3,ENG,
SMAD9,CAV1andKCNK3.FamilialPPHisinheritedasanautosomaldominantdisorderwithalowgeneticpenetrance
somewillhavethegenes,butnotexhibitthephenotype.
Chronicthromboembolicdiseasecanbeidentifiedin30%ofprimarycases(OptionB)isincorrect.Recurrent
thromboembolicdiseaseisnotacauseofprimarypulmonaryhypertension,butisactuallyadifferentcondition(Group
4)orsecondaryintheoldscheme.
Spontaneousremissionistheruleinmorethanhalfthecases(OptionC)isincorrect.Overallprognosisispoor,and
spontaneousremissiondoesnotoccur.Mediansurvivalis23yearsafterdiagnosis.
Cannabisinhalationmayinducesimilardisease(OptionD)isincorrect.Thereappearstobeaclearcutrelationship
betweentheuseofappetitesuppressants(fenfluramine)andthedevelopmentofprimarypulmonaryhypertension
cannabisisnotknowntobeassociatedwithprimarypulmonaryhypertension.
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Question243of295
Whichoneofthefollowingisafeatureofcoarctationoftheaorta?
A Ifitoccursproximaltotheleftsubclavianartery,bloodpressureelevationmaybeevidentonlyintheleftarm
B Itisalwaysassociatedwithacontinuousmurmur
C Itisaccompaniedbyabicuspidaorticvalveinaround50to80%ofcases
D Itpresentswiththeinabilitytoaugmentcardiacoutputwithexercise
E Surgicalcorrectionusuallyresolvesthehypertension
Explanation
TheanswerisItisaccompaniedbyabicuspidaorticvalveinaround50to80%ofcases
Notethattheconverse,thepercentageofthosewithabicuspidaorticvalvewhoalsohavecoarctationismuchless,
ataround20%.Thisisintuitive,asbicuspidaorticvavlaearepresentinbetween0.5and2%(~1%)ofthe
population.
Ifitoccursproximaltotheleftsubclavianartery,bloodpressureelevationmaybeevidentonlyintheleftarm(OptionA)
isincorrect.Ifitarisesproximaltotheoriginoftheleftsubclavianartery,bloodpressuremaybeelevatedonlyintheright
arm.
Itisalwaysassociatedwithacontinuousmurmur(OptionB)isincorrect.Acontinuousmurmurmayonlybeheardifthe
obstructionissevere.
Itpresentswiththeinabilitytoaugmentcardiacoutputwithexercise(OptionD)isincorrect.Cardiacoutputresponseto
exerciseisnotaffectedunlessthereiscardiacfailure.
Surgicalcorrectionusuallyresolvesthehypertension(OptionE)isincorrect.Hypertensionmaypersistaftercorrection.
Multiplemechanisms,suchaspersistingabnormalitiesinbaroreceptorfunctionandhyperresponsivenessoftherenin
aldosteronesystemhavebeenpostulated.LifelongrigorousBPcontrolisrequired.Sincecoarctationcanrecur,careful
noninvasiveimagingwillalsoberequired.
41905
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Question244of295
A44yearoldmanpresentswitha2hourhistoryofseverecentralchestpain,whichworsenedsignificantlyinthe40
minutesbeforeadmissiontotheEmergencyDepartment.ECGshowsSTelevationintheanteriorleads.Hewasrecently
dischargedfollowingalaparotomyforintestinalobstruction.
Whatwouldbethebestlineoftreatmentforhim?
A Aspirinandclopidogrel
B Streptokinase
C Coronaryangioplasty
D Intravenousheparin
E Alteplase
Explanation
TheanswerisCoronaryangioplasty
ThesymptomsandinvestigationssuggestanacuteanteriorSTelevationmyocardialinfarctionandprimarycoronary
angioplastyisthepreferredtreatmentifavailablewithin120minutesoffirstmedicalcontact.Ingeneral,PCIis
consideredwithin12hoursoftheonsetofpain.Ifinordinatedelayisanticipated,orPCIisnotavailable,then
thrombolysisshouldbeconsidered.
Aspirinandclopidogrel(OptionA)isincorrect.Whilstaspirinandclopidogrelwillalsobeadministeredinthecourseof
coronaryangioplastytheyarenotthebestanswerhere.
Streptokinase(OptionB)isincorrect.PrimarycoronaryangioplastyinthegeneralMIpopulationissuperiorto
thrombolysis,andinparticularpostsurgerywheretherisksofbleedingarehigh.
Intravenousheparin(OptionD)isincorrect.Whilstaspirinandclopidogrelwillalsobeadministeredinthecourseof
coronaryangioplastyitisnotthebestanswerhere.
Alteplase(OptionE)isincorrect.PrimarycoronaryangioplastyinthegeneralMIpopulationissuperiortothrombolysis,
andinparticularpostsurgerywheretherisksofbleedingarehigh.
41867
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Question245of295
A63yearoldsmokerisadmittedwithnausea,sweatingandcentralcrushingchestpain.A12leadECGrevealsST
elevationinleadsII,IIIandaVF.
Whichcoronaryarteryismostlikelytohavebeenaffectedinthiscase?
A Circumflexartery
B Leftanteriordescendingartery
C Obtusemarginalartery
D Posterolateralartery
E Rightcoronaryartery
Explanation
TheanswerisRightcoronaryartery(RCA)
ECGchangesandvesselsinSTEMI
AnteriorMI:LADocclusionSTelevationinV1V4
LateralMI:LADocclusionSTelevationinV5,V6,aVL
InferiorMI:RCAocclusionSTelevationinII,III,aVF,reciprocaldepressioninaVL
InferiorMIwithRVinfarction:RCAocclusionSTelevationinII,III,aVF,V1andrightsidedV4lead
(V4R)
PosteriorMI:RCAorLCxocclusion:STdepressioninV1V2,STelevationinposteriorleadsifplaced
(V7V9)
STelevationinII,IIIandaVFrepresentsRCAterritoryinfarctions.ThereforeOptionCisthecorrect
answer.
Coronaryarteries
Therightcoronaryarterygenerallysupplies:
therightventricle
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theposteriorthirdoftheinterventricularseptum
theinferiorwalloftheleftventricle
aportionoftheposteriorwalloftheleftventricle.
In15%ofpatients,theposteriorinterventricularseptummaybesuppliedbyabranchoftheleftcircumflexartery:
thisisreferredtoasaleftdominantcirculation.
Theleftanteriordescendingandleftcircumflexcoronaryarteriesariseattheleftmaincoronaryarterybifurcation
andsupply:
theanteriorleftventricle
thebulkoftheinterventricularseptum(anteriortwothirds)
theapex
thelateralandposteriorleftventricularwalls.
Circumflexartery(OptionA)isincorrect.Asdescribedthisisnotinkeepingwiththefindingsintheclinicalscenario.
Leftanteriordescendingartery(OptionB)isincorrect.Asdescribedthisisnotinkeepingwiththefindingsintheclinical
scenario.
Obtusemarginalartery(OptionC)isincorrect.Asdescribedthisisnotinkeepingwiththefindingsintheclinical
scenario.
Posterolateralartery(OptionD)isincorrect.Asdescribedthisisnotinkeepingwiththefindingsintheclinicalscenario.
42038
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Question246of295
An80yearoldmanhasisolatedsystolichypertension.Healsosuffersfromstableangina,goutandperipheralvascular
disease.Hedoesnothavediabetes.
Whichoneofthefollowingantihypertensivesisbestsuitedforhiminitially?
A Bendrofluazide
B Frusemide
C Atenolol
D Modifiedreleasenifedipine
E Ramipril
Explanation
TheanswerisModifiedreleasenifedipine
Questionsregardingthecontrolofbloodpressure(BP)arecommonandeasytoanswer.Modifiedreleasenifedipine
isthecorrectanswer.NICEguidanceisthatthefirstlinetherapyforthemanagementofhypertensionovertheageof
80isacalciumchannelblocker,suchasmodifiedreleasenifedipine.
CurrentBPmanagementshouldfollowthealgorithmpresentedintheaccompanyingdiagram.
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Bendrofluazide(OptionA)isincorrect.Thisisnotfirstlinetherapy.
Frusemide(OptionB)isincorrect.Thisisnotfirstlinetherapy.
Atenolol(OptionC)isincorrect.Thisisnotfirstlinetherapy.
Ramipril(OptionE)isincorrect.Thiswouldbethecorrectchoiceiftherewasahistoryofheartfailureordiabetes,butwe
donothavethathere.
41914
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Question247of295
A41yearoldmanwithafamilyhistoryofsuddendeathpresentstocasualtywithasecondepisodeofcollapse.Heis
referredtotheCardiologyDepartmentforreview.Echocardiographyrevealsasymmetricalseptalhypertrophy,abnormal
systolicmotionoftheanteriormitralvalveleafletandnarrowingoftheleftventricularoutflowtract.The24h
electrocardiogram(ECG)monitoringasanoutpatientrevealsseveralperiodsofnonsustainedventriculartachycardia.
Whichoneofthefollowingwouldbemostappropriateforthemanagementofhisarrhythmia?
A Implantablecardioverterdefibrillator
B Oralamiodarone,200mgdaily
C Oralamiodarone,200mgtds
D Oralflecainide,100mgdaily
E Phenytoin,100mgpodaily
Explanation
TheanswerisImplantablecardioverterdefibrillator
Toanswerthisquestionyoushouldrecognisethepatienthasclassicalfeaturesofhypertrophiccardiomyopathy
(HCM).Inthiscondition,ageneticabnormalityofacardiacprotein(manygeneshavebeenidentified,including
troponinandactinabnormalities)leadstoabnormalmyocytedevelopmentandfunction.Inthemajority,therecanbe
significantassymetricalhypertrophythatinvolvestheseptum.Othervariantscanbemorechallengingtodiagnose
particularlythoseaffectingonlytheapex,whichispoorlyvisualiseduponechocardiograpy.Cardiaccontractionis
abnormalwithdynamicoutflowtractgradientswhichcancausecollapseshortlyafterexercise,aswellasabnormal
ventriculararrhythmias.HCMpatientswithconfirmedepisodeofabortedsuddendeathorthosewithhighrisk
featuresshouldbeofferedICDs.Hehasnonsustainedventriculartachycardiasandisatsignificantriskofsudden
death.Therefore,Disthebestanswer.
Hypertrophicobstructivecardiomyopathy
Managementinthepastwouldhavebeenmedicaltherapywithamiodarone,butrecentstudieshave
demonstratedsuperiorefficacyforimplantablecardioverterdefibrillators(ICDs).
Giventhatlongtermuseofamiodaroneisassociatedwithsignificantmorbidity,ICDsaretakingoverasthe
managementofchoice.
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Alternativetreatmentssuchasmyomectomy(surgicaldebulkingoftheseptum)andalchoholseptalablation
(medicalinfarctionoftheseptumbyinstillingalcoholintotheseptalarteries)willreduceoutflowgradients
andtheirsymptoms,butwillnotaffecttheriskofarrhythmia.
Oralamiodarone,200mgdaily(OptionB)isincorrect.Thisdosewouldnotadequatelyloadthepatientwithamiodarone.
Oralamiodarone,200mgtds(OptionC)isincorrect.Amiodaronewillprovidebenefit,butmaynotpreventsuddendeath.
ICDshavesuperiorityhereandarethereforeabetteranswer.
Oralflecainide,100mgdaily(OptionD)isincorrect.Flecainideisnotappropriateinthesepatientswithstructurally
abnormalhearts.
Phenytoin,100mgpodaily(OptionE)isincorrect.Phenytoinhasnoroleinthemanagementofarrhythmia.
42021
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Question248of295
A50yearoldmanwithlongstandinghypertensionpresentsacutelywithseverechestpainradiatingthroughtohisback.
Helooksunwell,witharestingtachycardia(110bpm)andbloodpressureof150/96mmHg.Therearenomurmursand
neurologicalexaminationisnormal.AnurgentCTscanofhischestconfirmstypeAaorticdissection.Thelocal
cardiothoraciccentreiscontactedandurgenttransferarranged.Hehasreceivedappropriateopiateanalgesia.
Whatadditionaldrugtreatmentshouldbeinstigatedaspartofhisimmediatetreatmentplan?
A Intravenousglyceryltrinitrate(GTN)
B Intravenouslabetalol
C Intravenousnitroprusside
D Oralamlodipine
E Oralenalapril
Explanation
TheanswerisIntravenouslabetalol
TypeAdissectioninvolvestheascendingaorta,andtreatmentwithurgentsurgicalinterventionisrecommended
unlessseverecomorbiditywouldprecludethepatientfromsurgery.
Immediatemanagementincludestheliberaluseofopiatesforcompletepainrelief,therebydecreasingthe
sympatheticdrive.
Meticulousbloodpressurecontrolisvitalwhileawaitingsurgery/transfer,inanattempttoreducethechancesof
extensionorrupture.Drugsthatreducecardiaccontractility(haveanegativeinotropiceffect)arepreferred.
Shortactingintravenousblockers(eglabetalol)arethefirstchoicedrugsastheyreducebothbloodpressureand
theforceofcardiacejectionwhichmaythereforelimitextensionofthedissection.
IntravenousGTN(OptionA)isincorrect.IVGTNisonlyusediftheotherdrugsarenotrapidlyavailable.
Intravenousnitroprusside(OptionC)isincorrect.IfblockersarecontraindicatedthenIVsodiumnitroprussideor
calciumchannelblockers(IVdiltiazem)maybeappropriatealternatives,buttherearenofeaturessuggesting
contraindicationtolabetalolinthiscase.
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Thefollowingwouldbecontraindicationstousingblockers:
hypersensitivitytodrug/class
severeasthma
heartblock
uncompensatedheartfailure
bradycardia(heartrate<60bpm)
severechronicobstructivepulmonarydisease
hypotension.
Oralamlodipine(OptionD)isincorrect.Drugswithashorthalflifeareimportantsincehaemodynamicscanchange
rapidlyandthedrugmayneedtobestoppedurgently.Intravenousdrugsareessentialandthereforethisoptionisnot
suitable.
Oralenalapril(OptionE)isincorrect.Drugswithashorthalflifeareimportantsincehaemodynamicscanchangerapidly
andthedrugmayneedtobestoppedurgently.Intravenousdrugsareessentialandthereforethisoptionisnotsuitable.
41930
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Question249of295
A55yearoldmanwitha7yearhistoryofType2diabetescomestotheEmergencyDepartmentwithcentralcrushing
chestpainradiatingdownhisleftarm.Healsohashypertensionandsmokes15cigarettesperday.Medicationincludes
Metformin500mgBD,Ramipril,AtorvastatinandAspirin.OnexaminationhisBPis152/82mmHgpulseis85/minand
regular.Therearebilateralbasalcracklesonauscultationofthechest,andthereisnoankleswelling.HisBMIis30.
Investigations
Hb 13.1g/dl
WCC 8.7x109/l
PLT 191x109/l
Na+ 137mmol/l
K+ 4.3mmol/l
Creatinine 122micromol/l
Glucose 8.3mmol/l
HbA1c 53mmol/mol(7.0%)
ECG markedanteriorSTdepression
Whichofthefollowingisthemostappropriatewaytomanagehisdiabetesduringthisacuteepisode?
A Addbasalinsulinpermanently
B ContinueMetforminatthepresentdose
C IncreasedMetforminto1gBD
D Movetoinsulinslidingscalefor48hrs
E Transitiontopermanentbasalbolusregime
Explanation
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TheanswerisContinueMetforminatthepresentdose
DatafromanearlystudyofintensiveinsulinisationatthetimeofACS(theDIGAMI1study),suggestedtheremightbea
benefit.UnfortunatelythiswasnotborneoutintheDIGAMI2study,whichsuggestedatrendtoincreasedeventsinthe
grouptreatedwithintensiveinsulinisation,possiblyassociatedwithincreasedhypoglycaemia.Forthisreasonifcontrolis
relativelygood,(ashere),andthereisnoindicationforinsulinisation,patientsmaycontinueontheirnormalbackground
medication.Overthelongerterm,insulinhasnotbeenshowntobeofbenefitinreducingcardiovasculareventsinthe
secondarypreventionpopulationwithType2diabetes,(thenegativeACCORDandVADTstudies).Thereissome
controversyaboutwhethermetforminmayincreasetheriskofcontrastnephropathy.Informationtosupportthisasarisk
ishoweverlimited,andcurrentevidencepotentiallysupportsabenefitofcontinuingmetformin.Intheeventthereis
evidenceofhaemodynamicinstability,dosingcanofcoursebetemporarilyceasedaroundthetimeofangiography.
40159
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Question250of295
A79yearoldmanknowntohavechroniccongestiveheartfailureisreadmittedwithworseningheartfailure.His
furosemide(frusemide)dosageisincreasedto200mg/dtoaidthereliefofhissymptoms.Hisothermedicationsare
bendroflumethiazide,ramiprilandbisoprolol.
Whichoneofthefollowingeffectsismostlikelytobeencountered?
A Hyperkalaemia
B Hypercalciuria
C Hypermagnesaemia
D Hyperuricaemia
E Hypoalbuminaemia
Explanation
TheanswerisHyperuricaemia
Tubularhandlingofuricacidiscomplex,withbothreabsorptionandsecretionoccurringintheproximaltubule
Diureticscaninterferewitheitheroftheseprocessestherebycausinghyperuricaemia(hencethecorrectanswer)
Theeffectisusuallydosedependentandfrequentlyasymptomatic
Clinicalgoutismorelikelyifthepatientisalsoextracellularfluidvolumedepleted
Diureticscancauseametabolicalkalosisresultingfromchloridelossandextracellularfluidvolumecontraction.
Ototoxicityisanuncommonsideeffectoccurringwithhighdoseloopdiuretictherapy.Ithasbeennotedinpatients
withrenalfailurewhoaregivenhighdose(>2g/d)infusiontherapy.
Hyperkalaemia(OptionA)isincorrect,asloopandthiazidediureticscausehypokalaemiabyincreasingpotassium
deliverytothedistaltubule,whichstimulatesthealdosteronesensitivesodiumpumptoincreasesodiumresorptionatthe
expenseofpotassium.Potassiumsparingdiureticssuchasamiloride(anepithelialsodiumchannelblocker),and
spironolactone(aldosteroneantagonist)cancausehyperkalaemia.
Hypercalciuria(OptionB)isincorrect.Loopdiureticsdoincreasetherenalexcretionofcalcium,andhydrationcombined
withfurosemideistraditionallythefirstlinetreatmentofhypercalcaemia.However,outsidethiscontext,hypercalciuriais
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notadominantclinicalfeaturewhencomparedtohyperuricaemia.
Hypermagnesaemia(OptionC)isincorrect.Diureticscancauseotherelectrolytedisturbances,including
hypomagnesaemiaandhyponatraemiabutthisisnotthemostlikelyoptionofthosegiven.
Hypoalbuminaemia(OptionE)isincorrect.Diureticswillincreaseratherthanreduceserumalbuminlevels,throughtheir
effectsoncirculatingvolume.
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Question251of295
A32yearoldladyisnotedtohavealoudfirstheartsoundwithareversedwidelysplitsecondheartsoundon
auscultation.Shehasnopreviouscardiachistoryalthoughhasrecentlybegunsufferingfrompalpitations.
Whichcardiologicaldiagnosisisshemostlikelytohave?
A Hypertrophiccardiomyopathy
B Leftbundlebranchblock
C Mitralstenosis
D Rightbundlebranchblock
E WolffParkinsonWhitesyndrometypeB
Explanation
TheanswerisWolffParkinsonWhitesyndrometypeB
Splittingofthesecondheartsound
Thefirstheartsoundistheclosureofthemitralandtricuspidvalvesanddenotestheendofdiastole.
Aloudfirstheartsound(S1)istypicalofmitralstenosisifthevalveispliable.Therefore,mitralstenosisis
notcorrect,asthisisanabnormalityofthefirstheartsoundandisnotrelatedtosplittingofthesecondheart
sound.PatientswithmitralstenosiswillhavenormalphysiologicalsplittingofS2.Thisquestionstatesthe
patienthasreversedsplittingrulingoutmitralstenosis.
Thesecondheartsoundistheclosureoftheaorticvalve(A2)followedbytheclosureofthepulmonaryvalve(P2).
Innormalconditions,deepinspirationcausesincreasedvenousreturntotherightventricle,whichdelaystheclosure
ofP2slightlythisiscalledphysiologicalsplitting.
ReversedsplittingofS2iscausedbyoneofthefollowing:
delayedA2(egleftbundlebranchblock(LBBB),aorticstenosis(theaorticleafletsarethickenedandso
closeslowly),hypertrophicobstructivecardiomyopathy)
earlyP2(egWolffParkinsonWhite(WPW)typeBwheretherightsidedaccessorypathwaycausesearly
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RVdepolarisation).
RightbundlebranchblockcauseswidesplittingofS2becauseitdelaysP2(ieitenhancesphysiologicalsplitting).
S1issoftifclosureofthemitralvalveisdelayed(egLBBB,longPR),butloudifmitralortricuspidclosureisearly
(egWPWtypeB).Therefore,inthiscase,withaloudS1andwidelysplitS2,thenWPWtypeBisthemostcorrect
answer.
Hypertrophiccardiomyopathy(OptionA)isincorrect.Thisisnotthemostlikelydiagnosisherebasedonthepresentation.
Leftbundlebranchblock(OptionB)isincorrect.Thisisnotthemostlikelydiagnosisherebasedonthepresentation.
Mitralstenosis(OptionC)isincorrect.Asdescribedthisisanabnormalityofthefirstheartsound,andisnotrelatedtothe
splittingofthesecondheartsound.
Rightbundlebranchblock(OptionD)isincorrect.RBBBalonewouldnotaccountfortheloudS1.
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Question252of295
A40yearoldwomanpresentswitha3monthhistoryoffatigue,weightloss,nightsweatsandadegreeofexertional
dyspnoea.Herpasthistoryincludesaprostheticmitralvalvereplacement2.5yearsago.Sheispyrexialwithevidenceof
mitralregurgitationandsplinterhaemorrhages.Echoconfirmsmoderateparavalvularmitralregurgitation.Bloodcultures
aretakenandadiagnosisofinfectiveendocarditisismade.
Whatisthemostlikelyinfectingorganisminthiscase?
A Coxiellaburnetii
B Enterococcusspp
C Staphylococcusaureus
D Staphylococcusepidermidis
E Streptococcusviridans
Explanation
TheanswerisStreptococcusviridans
Thequestionprovidesaclassicexampleofendocarditisinapatientwithavalvereplacement.Knowingwhenthe
valvewasreplacediskeytoansweringthisquestion.
Inpatientswitharecentvalvereplacement(certainlywithin69months,butpossiblyupto1year)thecausative
organismismorelikelytobeacoagulasenegativestaphylococcisuchasStaphylococcusepidermidis,whichisa
skincommensal.Itcanaccessthevalveintheearlypostoperativephaseduetothepresenceofinvasivelines(eg
centrallines)itwillformabiofilmonthemechanicalvalveandthenmanifestatalaterstage.Morevirulent
organismswouldmanifestearlier.
After1year,theorganismsareconsistentwithnativevalveendocarditis.Themostcommonorganismcontinuesto
beStreptococcusviridansamouthorganismthatentersthebloodstreamafterteethbrushingordentalwork.Inthis
case,thepatienthadthevalvereplacementsometimeago,andthereforeStreptococcusviridansisthecorrectanswer
andnottheotheroptions.
Otherorganismsfornativevalves:
Enterococci 1015%
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Other 2025%
Coagulasenegative 13%
Coxiellaburnetii(OptionA)isincorrect.Asdescribedthisisnotthemostlikelyorganism.
Enterococcusspp(OptionB)isincorrect.Asdescribedthisisnotthemostlikelyorganism.
Staphylococcusaureus(OptionC)isincorrect.Asdescribedthisisnotthemostlikelyorganism.
Staphylococcusepidermidis(OptionD)isincorrect.Asdescribedthisisnotthemostlikelyorganism.
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Question253of295
A72yearoldmanpresentstotheCardiologyClinicforreview.Hehasahistoryofcentralchestachewhenhegoesoutin
thecoldtowalkthedogoverthepast18months.Healsoreportsaminorchestnigglewhenhewalksupasteephill
nearhishome.Hesmokes10cigarettesperdayandhasdonesoforthepast50years.HehashypertensionwithaBPof
155/90mmHgontreatment,andanLDLcholesterolof3.9mmol/l.MedicationincludesRamipril,Aspirinand
Bisoprolol.
Whichofthefollowingistheoptimalnextstep?
A Angiography
B Exercisetest
C Isosorbidedinitrate
D Myocardialperfusionscan
E Nebivulol
Explanation
TheanswerisIsosorbidedinitrate
NICEguidancesuggestsinthepresenceofstableangina,withatypicalhistory,coronaryarteryinvestigationisnot
neededifthepresenceofcoronaryarterydisease(CAD)ispredictedtobe90%orhigher.Inthiscase,givenhistypical
history,age,smoking,hypercholestrolaemiaandhypertension,hischestpainisalmostcertainlyrelatedtoCAD,assuch
thenextstepistherapyforhisangina.Nebivulolisindicatedforthetreatmentofhypertensionandheartfailure.If
coronaryarterydiseaseissuspectedandthepredictedriskofCADislessthan90%,myocardialperfusionscanningor
angiographywouldbeinvestigationsofchoice.
http://www.nice.org.uk/guidance/CG95(http://www.nice.org.uk/guidance/CG95)
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Question254of295
A40yearoldwomanisadmittedwithastrokeafteraprolongedpyrexialillness.HerGPwasunclearastothepotential
causeofherfeversandhadprescribedacourseoforalCoamoxiclavintheexpectationitwouldcoverbothrespiratory
andurinarypathogens.Onexaminationsheisinsinusrhythm,hassplenomegalyandapansystolicmurmurattheapex.
Bloodculturesconfirmaninfectiveendocarditis.
Whichoneofthefollowingisthemostcommoncausativeorganism?
A Streptococcusviridans
B Staphylococcusaureus
C Streptococcusbovis
D Gramnegativebacilli
E Staphylococcusepidermidis
Explanation
TheanswerisStreptococcusviridans
Membersoftheviridansgroupofstreptococciarethecommonestcauseofsubacuteendocarditisonnativevalves
thesecommensalsoftheupperrespiratorytractmayenterthebloodstreamonchewing,toothbrushingoratthetime
ofdentaltreatment.Despiteanincreaseinstaphylococcalinfections,streptococciviridansarestillthemostcommon
causeandthereforethisisthecorrectanswer.
Prevalencesoforganisms
Theprevalencesoforganismscausinginfectiveendocarditisareshowninthetablebelow
Enterococci 1015%
Other 2025%
Coagulasenegative 13%
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Staphylococcusaureus(OptionB)isincorrect.Staphylococcusaureusisacommoncauseofacuteendocarditis,
originatingfromskininfections,abscesses,vascularaccesssitesorintravenousdrugmisuse.Thereisisnothingtosuggest
skininfectionsorIVdrugabuseandthereforethisisincorrect
Streptococcusbovis(OptionC)isincorrect.Streprococcusbovisisalesscommonlydetectedpathogenininfective
endocarditis.Itisassociatedwithcolonicpathologyincludingcarcinoma,sooncedetectedfurthergastrointestinal
investigationisappropriate.
Gramnegativebacilli(OptionD)isincorrect.GramnegativebacillioftheHACEKgrouparelesscommonlyfoundin
infectiveendocarditisandaredifficulttoculture.Notonlyaretheynotthemostcommon,butthequestiondoesnotstate
theneedforspecificculturemediaorlongincubationtimes.
Staphylococcusepidermidis(OptionE)isincorrect.Staphylococcusepidermidisareskincommensalsthatarethemost
commonlyfoundpathogenassociatedwithearly(<90daysofsurgery)prostheticvalveendocarditis.Typically,these
bacteriaenterthebloodstreamfromtheskinviacentrallinespostoperatively.Thereisnosuggestionofrecentsurgery
andthereforethisisnotthecorrectanswer.
41874
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Question255of295
A21yearoldwomancomestotheclinicforreview,havingreturnedearlyfromasummerjobasanassistantinadiving
schoolbecauseofanepisodeofdecompressionsickness.Heronlypasthistoryofnoteispersistentmigrainedespitea
rangeofmedicaltherapies,andshetakesnoregularmedications.HerBPis120/80mmHg,pulseis65/minandregular.
Therearenomurmursandherchestisclear.HerBMIis21.Routinebloodsareunremarkable.
Whichofthefollowingisthemostusefulinvestigationtofindthecauseofhersymptoms?
A Contrastechocardiography
B CThead
C CXR
D MRAcerebralcirculation
E Transcranialdoppler
Explanation
TheanswerisContrastechocardiography
Persistentmigraineisarecognisedpresentationofpatentforamenovale(PFO),thepotentialunderlyingdiagnosishere.
PFOisalsoassociatedwithincreasedriskofdecompressionsicknessbecauseofthepropensityfornitrogenbubblesto
passthroughthedefect.Afterobtainingoptimalviewsoftheatrialseptumontransthoracicortransesophageal
echocardiography,abolusofagitatedsalineisinjectedintoanantecubitalvein.Subsequently,microbubblesappearinthe
rightatrium.ThestudyisdeemedpositiveforPFOifthemicrobubblesappearintheleftatriumwithin3cardiaccyclesof
theirappearanceintherightatrium.Transcranialdopplercanestablishthepresenceofashunt,butitdoesnotestablishthe
locationoftheshunt.
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Question256of295
A60yearoldmancomplainsofdizzinessandpalpitations.AnECGshowstachycardia,broadQRScomplexes,AV
dissociationandthepresenceofcapturebeats.Whatisthemostprobablediagnosis?
A Sustainedventriculartachycardia
B Ventricularfibrillation
C Torsadesdepointes
D Ventricularprematurebeats
E Atrialtachycardia
Explanation
InterpretingECG
Ventriculartachychardia
Thefeaturesdescribedinthequestionarehighlysuggestiveofsustainedventriculartachycardia
Ventricularfibrillation
Inventricularfibrillation,thereisveryrapidandirregularventricularactivationwithnomechanicaleffect
Thepatientispulselessandrapidlybecomesunconscious
TheECGshowsshapelessrapidoscillationswithnohintoforganisedcomplexes
Torsadesdepointes
Intorsadesdepointes,ventricularrepolarisationisgreatlyprolonged(longQTsyndrome)
ItischaracterisedonECGbyrapid,irregular,sharpcomplexesthatcontinuouslychangefromanuprighttoan
invertedposition
ProlongedQTintervalsarealsoseenbetweenspellsoftachycardiaorimmediatelyprecedingtheonsetof
tachycardia
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Ventricularprematurebeats
BroadQRScomplexesmaybeseeninventricularprematurebeats,but,followingaprematurebeat,thereis
usuallyacompensatorypause
Thisconditionisusuallyasymptomatic
Atrialtachycardia
Inatrialtachycardia,thePwavesareabnormallyshapedandoccurinfrontoftheQRScomplexes
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Question257of295
A65yearoldwomanwithahistoryofheavysmokingpresentsforreview.Shehaswokenduringtheearlyhoursofthe
morningforthesecondtimewithshortnessofbreathsobadthatshehadtoflingopenthewindows.Onexaminationthere
arecracklesinthelungbases,herchestXray(CXR)showsbilateralfluffyperihilarshadowing.ECGrevealssmall
anteriorQwavesandasinustachycardiaof105bpm.
Whatdiagnosisfitsbestwiththisclinicalpicture?
A ExacerbationofCOPD
B Idiopathicpulmonaryfibrosis
C Pulmonaryembolus
D Pulmonaryoedema
E Sarcoidosis
Explanation
TheanswerisPulmonaryoedema
Theclinicalpresentationisclassicforpulmonaryoedema.Thedescriptionofparoxysmalnocturnaldyspnoeais
classicalandfitsbestwithananswerofPulmonaryoedema.ThepresenceoffluffyCXRchangesandtheevidence
ofpreviousmyocardialinfarctionallpointtopulmonaryoedema.
Leftventricularfailure
Thehistoryofparoxysmalnocturnaldyspnoea,chestXraysuggestiveofpulmonaryoedemaandECGwith
changesofapreviousanteriormyocardialinfarctionsuggeststhatthiswomanissufferingfromleftventricular
failure.
Ahistoryofpinkfrothysputumanddistendedneckveinsonexaminationwouldalsocontributetothediagnosis.
Causesofpulmonaryoedema
Causesofpulmonaryoedemaincludeoacutemyocardialinfarction
hypertensiveheartfailure
valvulardisease
ventricularseptaldefect
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cardiactamponade
cardiacarrhythmias
endocarditis
myocarditis
cardiomyopathy.
Echocardiography
Echocardiographyisusefultodeterminethedifferentialdiagnoses,andprovidesinformationabout
valvulardisease
diastolicvssystolicdysfunction
ejectionfraction
estimatesofrightsidedpressures.
Management
Theacutemanagementofpulmonaryoedemaincludes
oxygentherapy
intravenousfurosemide
vasodilatortherapywithivnitrates.
Manyacutewardsalsohaveintermittentpositivepressureventilationavailable,ausefuladjuncttomedicaltherapy
forleftventricularfailure.
ExacerbationofCOPD(OptionA)isincorrect.ExacerbationofCOPDistypicallyassociatedwithwheezeandmayhave
aninfectivecomponent,withincreasedsputumproductionorpurulence.
Idiopathicpulmonaryfibrosis(OptionB)isincorrect.Inpulmonaryfibrosispatientshaveaslowpresentationwith
gradualdecline.Theremaybeclubbing,cyanosisandtheyhavebibasalcrepitationswithgroundglasschangeson
radiologicalimaging.
Pulmonaryembolus(OptionC)isincorrect.PulmonaryembolusdoespresentacutelybutwouldnothaveCXRchanges
withperihilarshadowing.
Sarcoidosis(OptionE)isincorrect.Sarcoidosisisamultisystemdisorderandpatientswillhavefatigue,weightlossand
jointproblems.Thereistypicallyerythemanodosumontheshins.Lungmanifestationsarecommonandpatientspresent
andbehavesimilarlytolungfibrosis.
42006
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Question258of295
A16yearoldgirlpresentstotheEmergencyDepartmentwithacollapseandpalpitationsafterattendingherendofterm
schooldisco.Theonlymedicationhistoryofnoteincludesarecentantibioticprescriptionforaninfectedtoe.Pastmedical
historyincludesallergytopenicillin.Familyhistoryrevealsthathermotherdiedsuddenlyattheageof34whenthe
daughterwas3yearsold.Oneauntandoneunclehavealsopassedawaysuddenly.Electrocardiogram(ECG)reveals
sinusrhythmintheEmergencyDepartment,buttheQTintervalisprolongedat550ms(corrected).Whichoneofthe
followingconditionsismostlikelytoberelatedtothepatientscollapse?
A WolffParkinsonWhitetypeA
B WolffParkinsonWhitetypeB
C CongenitallongQTsyndrome
D LownGanongLevinesyndrome
E Ebstein'sanomaly
Explanation
CongenitallongQTsyndrome
TheQTprolongationandhistoryofsuddendeathinthefamilysuggeststhepossibilityofcongenitallongQT
syndrome
QTintervalcanbeprolongedinassociationwithanumberofmedications,including:
erythromycin(prescribedforthepatientsfoot)
ketoconazole
antihistamines
antiarrhythmics
Theconditionisassociatedwithtorsadesdepointesventriculartachycardia
LangeNielsensyndromeisonesyndromeofQTprolongation,whichhasbeendescribedinassociationwith
congenitaldeafnessRomanoWardsyndromeisassociatedwithnormalhearing
LownGanongLevinsyndrome
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TheLownGanongLevinesyndrome(LGL)isusuallyconsideredinaclassofpreexcitationsyndromesthat
includestheWolffParkinsonWhitesyndrome(WPW),LGLandMahaimtypepreexcitation
TheoriesproposedtoexplainLGLhavecenteredaroundthepossibleexistenceofintranodalorparanodalfibers
thatbypassallorpartoftheatrioventricular(AV)node
CriteriaforLGLincludePRintervallessthanorequalto0.12s(120ms),normalQRScomplexdurationand
occurrenceofsupraventriculartachycardiabutnotatrialfibrillationoratrialflutter
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Question259of295
A17yearoldyouthisbroughttotheGPbyhismother.Hewaspreviouslyseen2weeksearliersufferingfromacute
pharyngitis.Histeethareingenerallypoorcondition,butotherwisethereisnopreviousmedicalhistory.Onexamination
heisfebrilewithatemperatureof38.2C,andhasapolyarthritisaffectinghisknees,ankles,wristsandelbows.Healso
appearstohavesubcutaneousnodulesoverhiselbows,andmitralregurgitationoncardiovascularexamination.
Whatdiagnosisfitsbestwiththisclinicalpicture?
A Bacterialendocarditis
B Congenitalvalvularheartdisease
C Juvenilerheumatoidarthritis
D Rheumaticfever
E Scarletfever
Explanation
TheanswerisRheumaticfever
Thepatienthascharacteristicfeaturesofrheumaticfever.
Physicalfindingssuggestiveofrheumaticfeverinclude
historyofpreviouspharyngitis
fever
polyarthritis
carditis(includingthemitralregurgitationmurmur)
presenceofsubcutaneousextensorsurfacenodules.
Laboratorytestingsuggestiveofthediagnosiswouldinclude
apositiveantistreptolysinOtitre(peaksat45weeksafterastreptococcalthroatinfection)
raisederythrocytesedimentationrate
Creactiveprotein.
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Aleucocytosisisalsosuggestiveofrheumaticfever.
Treatment
AcutetreatmentincludesacourseofpenicillintoeradicatethroatcarriageofgroupAstreptococciwherethereis
carditisorarthritis,aspirinorprednisolonemaybeadded,butspecialistadviceisadvised.
Erythromycinmaybeusedinpenicillinallergicpatients.
Bacterialendocarditis(OptionA)isincorrect.Bacterialendocarditiswouldpresentwithfatigue,feversandweightloss.
Patientswouldhavesplinterhaemorrhagesofthenailbeds(>5)andhavehaematuria.Theteethcanbeasourceof
infection.
Congenitalvalvularheartdisease(OptionB)isincorrect.Congenitalvalvularheartdiseaseimpliesthepossibilityofa
cyanoticconditionthereisnoovertcyanosisorfailuretothriveinthehistory.
Juvenilerheumatoidarthritis(JRA)(OptionC)isincorrect.JRAfeatureslowgradefeverwithmultiplejointpainsand
salmonpinkrash.Althoughthispatientdoeshavemultiplejointsaffected,acharacteristicfeatureofJRAismissingthat
ofdiscretepinkpatchesthatcomeandgooverthecourseofhours.Thesepatchescanmigrate,typicallyoverthetrunkand
pressureareas.
Scarletfever(OptionE)isincorrect.Scarletfeverisaninfectiousdisorderinchildrenthatfeaturesasorethroat,feverand
aredrash.ItiscausedbygroupAstreptococcus.Therashcanbealloverthetrunkandonthecheeks,sparingthearea
aroundthemouth(cicumoralpallor).Thetongueischaracteristicallybrightredwithastrawberryappearance.Noneof
theseispresentinthiscase,makingthisanunlikelydiagnosis.
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Question260of295
A50yearoldmanhadamechanicalaorticvalvereplacementforsevereaorticstenosis,andwasdischargedhome10
dayslater.Twoweekslater,hestartedfeelingunwellandhadlethargy,nauseaandpyrexiaof38.3C.Echocardiography
showedvegetationsontheaorticvalve.
Whichoneofthefollowingisthemostlikelycausativeorganism?
A Enterococci
B GroupDstreptococci
C Haemophilusinfluenzae
D Staphylococcusepidermidis
E Streptococcusviridans
Explanation
TheanswerisStaphylococcusepidermidis
Youcanbereasonablyassuredthataquestiononinfectiveendocarditiswillcomeupfortheexam,sostudythis
topic,particularlythemostlikelyorganismsindifferencecircumstancesandantibioticregimens,indepth.
Thispatienthasdeveloped,bythe2009ESCguidelines,early(<1year)leftsidedprostheticvalveendocarditis.
Staphylococcusepidermidisisthemostlikelycauseinthiscircumstance,occurringinaround50%ofcases.
Staphylococcusaureusisthenextmostfrequent,accountfor10%ofcases.
Enterococci(OptionA)isincorrect.Enterococcirarelycauseinfectiveendocarditis.
GroupDstreptococci(OptionB)isincorrect.GroupDstreptococcirarelycauseinfectiveendocarditis.
Haemophilusinfluenzae(OptionC)isincorrect.HaemophilusinfluenzaeisamemberoftheHACEKgroupoforganisms
thatcanrarely(upto3%ofcases)causeinfectiveendocarditis.
Streptococcusviridans(OptionE)isincorrect.Streptococcusviridansisthemostlikelycauseinnativevalve
endocarditis,occurringin30to40%ofcases.
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Question261of295
Whichoneofthefollowingstatementsismostindicativeofmyocardialischaemia?
A Associatedshortnessofbreath
B Claudication
C Dizziness
D Radiationtojaw
E Reliefbyglyceryltrinitrate
Explanation
Angina
Thepainofanginausuallyradiatesoutfromthechestthecommonestsitesofradiationincludethefollowing:
theneckandthroat(causingafeelingofchoking,strangulationorsuffocation)
thejaw(andmaybeinterpretedastoothacheorproblemswithdentures)
downoneorbotharmsthisisusuallyfeltdowntheinside,undertheaxillatotheinnertwofingers(by
contrast,muscularpainusuallyrunsovertheshoulderanddowntheoutsideofthearm)
Othersitesincludetheabdomen,theback,andareasofpreviousinjury
Anginaisoftenmisinterpretedasindigestion
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Question262of295
A75yearoldmanpresentstotheEmergencyDepartmentwithahistoryofsuddencollapse.Thisoccurredunexpectedly
whilehewaswalkinghisdog.Therehavebeennosimilarepisodesinthepast.Onexaminationtherewerenopositive
findings.AnECGperformedwithcarotidsinusmassagerevealeda5secondpause.
Whichoneofthefollowingstatementsistrue?
A Carotidsinushypersensitivityisduetoatherosclerosis
B Carotidsinusmassageiscontraindicatedinpatientswithcarotidvasculardisease
C Apermanentpacemakerhasnoroleinthemanagementofthesepatients
D Carotidsinushypersensitivityisrelatedtovertebrobasilarischaemia
E Carotidsinusmassageiscontraindicatedinpatientstakingblockers
Explanation
TheanswerisCarotidsinusmassageiscontraindicatedinpatientswithcarotidvasculardisease
Thehistoryisconsistentwithcarotidsinushypersensivityandtheuseofcarotidsinusmassage.Priortoperforming
carotidsinusmassageyoumustlistenoverthecarotidvesseltoassessforbruitthiswouldsuggestatherosclerosis.
Thespecificriskisofcausingstrokefromemboliorvesselocclusionfromfirmmassage.
Carotidsinushypersensitivity
Carotidsinusbaroreceptorsconsistofsensorynerveendingslocatedintheinternalcarotidarteryjustabovethe
bifurcationofthecommoncarotidartery
Typesofhypersensitivity
Cardioinhibitorycarotidsinushypersensitivityisdefinedascardiacasystoleof>3s
Thepurevasodepressortypeisdefinedasasystolicbloodpressuredropof>50mmHg(intheabsenceof
significantbradycardia)
Amixedtypeconsistsofacombinationofcardioinhibitoryandvasodepressorresponses
Asatrioventricularblockcanoccurduringtheperiodsofhypersensitivecarotidreflex,someformofventricular
pacing,withorwithoutatrialpacing,isgenerallyrequired
Absolutecontraindicationstosinusmassageinclude:
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Myocardialinfarction
Transientischaemicattack(inlast3months)
Cerebrovascularaccident(inlast3months)
Carotidarteryocclusion
Previousventriculararrhythmia
Carotidsinushypersensitivityisduetoatherosclerosis(OptionA)isincorrect.Themechanismresponsibleforcarotid
sinushypersensitivityisunknown,butpossibilitiesinclude
ahighlevelofrestingvagaltone
hyperresponsivenesstoacetylcholine
anexcessivereleaseofacetylcholine.
Apermanentpacemakerhasnoroleinthemanagementofthesepatients(OptionC)isincorrect.Asdescribed,AVblock
canoccurduringperiodsofhypersensitivecarotidreflex,someformofventricularpacing,withorwithoutatrialpacingis
generallyrequired.
Carotidsinushypersensitivityisrelatedtovertebrobasilarischaemia(OptionD)isincorrect.Carotidsinus
hypersensitivityisnotrelatedtovertebrobasilarischaemia.
Carotidsinusmassageiscontraindicatedinpatientstakingblockers(OptionE)isincorrect.Thelistofabsolute
contraindicationshasalreadybeendescribed.
41860
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Question263of295
A45yearoldmanisadmittedtotheEmergencydepartmentfromanofficepartyaftercomplainingofaseverefrontal
headache,theworsthehaseverhad.Onfurtherquestioningheadmitstoheadachesonmostmorningsoftheweek,likea
hangover.OnexaminationhisBPis190/100mmHg,pulseis84/minandregular.Hehasgrade4hypertensive
retinopathyandbibasalcracklesonauscultationofthechest.
Investigations
Hb 11.9g/dl
WCC 9.9x109/l
PLT 192x109/l
Na+ 138mmol/l
K+ 4.2mmol/l
Creatinine 182micromol/l
Renalultrasound Bilateralsmallkidneys
Whichofthefollowingistheoptimaltreatment?
A IVsodiumnitroprusside
B Oralramipril
C IVlabetalol
D Oralamlodipine
E Oralindapamide
Explanation
TheanswerisIVsodiumnitroprusside
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Thismanhasmalignanthypertension.OutofthetwoIVoptionsgiven,nitroprussideispreferredastreatmentsince
labetalolmaybeassociatedwithagreaterreductionincerebralbloodflow,andassuchmayprecipitatecerebral
ischaemia.TheoraloptionsarenotpreferredinthissituationastheoverallreductioninBPisnotasgreatasthatseen
withIVtherapy,andtitrationispotentiallylessprecise.
34355
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Question264of295
A42yearoldmanpresentstotheEmergencyDepartmentwithcentralcrushingchestpainradiatingdownhisleftarm.
AnECGshowsanteriorSTelevationandheisstented.Asubsequenttroponinissignificantlyraisedat1100,andhehas
abnormallipidswithtotalcholesterolof8.4mmol/l,HDLof0.7mmol/l,andatriglyceride4.2mmol/l.Other
investigationsincludingaTSHof0.7arenormal.
Whichofthefollowingisthemostlikelydiagnosis?
A Familialcombinedhyperlipidaemia
B Familialhypercholesterolaemia
C Familialhyperchylomicronaemia
D Familialhypertriglyceridaemia
E FamilialLCATdeficiency
Explanation
TheanswerisFamilialcombinedhyperlipidaemia
Thelipidpicturehere,withelevatedtotalcholesterolandelevatedtriglyceridesisconsistentwithcombined
hyperlipidaemia,asistheearlypresentationwithischaemicheartdisease.Themixedhyperlipidaemiaeffectivelyrulesout
inheritedhypertriglyceridaemiaorhypercholesterolaemia.LCATdeficiencyleadstocornealopacities,renalfailure,and
earlypresentationwithIHD.Hyperchylomicronaemiasyndromepresentsearlywithfailuretothrive,abdominalpainand
hepatosplenomegaly.
40161
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Question265of295
A70yearoldmanisbroughtintotheEmergencyDepartment.Heisunwellwithacoolperipheryandbloodpressureof
70/40mmHg.ECGshowsaregularbroadcomplextachycardiawitharateof190bpm.Heisunabletoprovideaclear
history,butarecentprescriptioninhiswalletshowsthatheistakingaspirin,ramipril,frusemideandspironolactone.An
arterialbloodgasisperformedintheEmergencyDepartmentshowsaraisedurea,acidosisandraisedpotassium.
Whatisthelikelyarrhythmia?
A Atrialfibrillation
B Atrialflutterwitha2:1block
C SVTwithaberrantconduction
D VT
E WolffParkinsonWhitesyndrome
Explanation
Ventriculartachycardia
Thispatientishaemodynamicallycompromisedasaconsequenceofthearrhythmia
Theprescriptionwouldsuggestthepresenceofunderlyingcardiacdiseasewithprobablecardiacdysfunction
Inthecontextofknownischaemicheartdiseaseorleftventriculardysfunction,abroadcomplextachycardia
shouldbeassumedtobeventriculartachycardia(VT)untilprovedotherwise
ECGcriteria
ManyECGcriteriaexisttoaidthedifferentiationofVTandsupraventriculartachycardia(SVT)withaberrancy
andinclude
AVdissociation
capturebeats
fusionbeats
extremeQRSaxis
concordanceacrossventricularleads
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ApreviousECGcanbeexceedinglyhelpful
Otherclinicalsigns
Subtleclinicalsigns,suchasintermittentcannonwavesinthejugularvenouspressureandavariablefirstheart
soundmaybepresent,inpatientswithAVdissociation
1388
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Question266of295
A21yearoldwomanhasahistoryofpalpitationsandlightheadedness.Theelectrocardiogram(ECG)showsashortPR
intervalandinferiorQwaves.Hersymptomsimprovewithatenolol25mg/day,butshehashadtwoshortepisodesof
similarsymptomsintheprevious24hours.
Whatisthelongtermmanagementofchoice?
A Anticoagulation
B Oralamiodarone
C Oraldigoxin
D Increasethedoseofatenolol
E Radiofrequencyablation
Explanation
TheanswerisRadiofrequencyablation
LongGanongLevineandWolffParkinsonWhitesyndromes
ThemanagementofWPWandLGLsyndromesissimilar:radiofrequencyablationisrecommendedforthese
patientsandcanbecurative.
RecurrentpalpitationswithashortPRintervalsuggestthepresenceofanaccessorypathway(atrioventricularre
entranttachycardia(AVRT)).WolffParkinsonWhite(WPW)isthemostwellknown,butforthediagnosisof
WPWthereshouldbedeltawave(slurredupstroke)andabroadeningoftheQRS.Inthiscase,thereisonlyashort
PRintervalthissuggestsLongGanongLevine(LGL)instead.Inthissyndromethereisanaccessorypathway
closethatconnectstheatriadirectlytothebundleofHissotheAVnodeisbypassed.Therearerapidpalpitations
withsupraventriculartachycardiastransmittedtotheventriclesatahighrate.
Itislikelyherpalpitationsandlightheadednesscomefromshortperiodsofsupraventriculartachycardia.
Anticoagulation(OptionA)isincorrect.Thiswouldnotbetherecommendedlongtermmanagementofchoice.
Oralamiodarone(OptionB)isincorrect.Longtermoralamiodaronetherapyisnotrecommendedinviewoftheageof
thispatient.
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Oraldigoxin(OptionC)isincorrect.Digoxinisnotrecommended,asitmayresultinanincreasedventricularrateand
worsenanycirculatorycompromiseduringattacksoftachycardia.
Increasethedoseofatenolol(OptionD)isincorrect.Atenololmaybeusefultomanageventricularrateduringperiodsof
tachycardia,butagainisasuboptimalchoiceforthispatientinthelongterm.
41993
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Question267of295
A30yearoldpilot,whoisotherwisefitandwell,isfoundtohaveaWPW(WolffParkinsonWhite)preexcitation
patternonaroutineECG.Thepilotdoesnotreportanysymptoms.
Whichoneofthefollowingisthemostsuitablemanagement?
A Amiodarone
B ClassIaantiarrhythmics
C Electrophysiologicalstudyforriskstratification
D LeavealoneandrepeatECGafter6months
E Radiofrequencycatheterablationofaccessorypathway
Explanation
TheanswerisRadiofrequencycatheterablationofaccessorypathway
Patientswithsymptomsattributabletotheaccessorypathway,withafamilyhistoryofsuddencardiacdeath,or
asymptomaticpatientsinwhomunpredictabletachyarrhythmiascouldaffecttheirownorotherswellbeingshould
proceeddirectlytoaradiofrequencycatheterablation.
Amiodarone(OptionA)isincorrect.Amiodaroneisanalternativetoablation,butnotinhighriskprofessionsorthose
whoaresymptomatic.
ClassIaantiarrhythmics(OptionB)isincorrect.ClassIa/Icantiarrhythmicsareanalternativetoablation,butnotinhigh
riskprofessionsorthosewhoaresymptomatic.
Electrophysiologicalstudyforriskstratification(OptionC)isincorrect.Electrophysiologicalstudyforriskstratification
canbeundertaken,butaswithalltestsdoesnothave100%sensitivityandspecificity.Insomehealthcaresystemsand
withoutthehighriskprofession,exercisetestingmaybeperformed:forthoseinwhomthedeltawaveislostduring
exercise,suggestingpreferentialconductionthroughtheAVNattimesofstress,agoodprognosisisexpected.
LeavealoneandrepeatECGafter6months(OptionD)isincorrect.Duetohisprofessionablationisrequired.
41917
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Question268of295
A50yearoldprofessorofeconomicspresentswitha6weekhistoryofprogressivebreathlessnessandbilateralankle
swelling.TheECGshowsinvertedpinV1andpartialLBBB.Echocardiographyconfirmsdilatedcardiomyopathy.
Whichoneofthefollowingstatementsistrue?
A Thereisnorelevanceofhistoryofalcoholabuse.
B Afamilyhistoryofasimilarproblemisunrelated
C Pastcytotoxicdrugtherapyisrelevant
D Viralillnessinthepastisunrelated
E Historyofpulmonarytuberculosisinthepastisrelevant
Explanation
TheanswerisPastcytotoxicdrugtherapyisrelevant
Chemotherapyagentsfromtheanthracyclineclass(suchasdoxorubicin),andtrastuzumab(Herceptin)are
cardiotoxicandimpairorcausemyocardialdysfunctionbyinterferingwithcardiomyocytefunction.ECGchanges
withabroadeningoftheQRScomplex,arrhythmiasandovertheartfailurecanoccur.
Inthemajorityofcasesofdilatedcardiomyopathy(DCM),nodefinitivecausecanbefound(idiopathic).
DCMischaracterisedbydilatationandimpairedsystolicfunctionoftheleftand/orrightventricle.
Aetiology
Theaetiologyisidiopathicinthemajorityofcases
DCMisfamilial(autosomaldominant)inatleast20%ofcasesandaroleofautoimmunityisproposedinthe
pathogenesisofthisdisease
About3040%ofpatientswithDCMhaveorganspecificantibodiesandthesemaybecomenegativewithdisease
progression
Thereisanassociationwithviral(coxsackievirusorHIV)infection,whichmaybeimmunerelated
FeaturesofDCM
ManypatientswithsystemicheartdiseasepresentwithfeaturesofDCM
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alcoholabuse
cytotoxicdrugtherapy,egdoxorubicin,cyclophosphamide
primaryheartmusclediseases,egamyloidosis
endstagecardiovasculardisease,egischaemic,rheumatic,congenital,systemichypertension
generaliseddisease,eghaemachromatosis,sarcoidosis
connectivetissuedisorders,egsystemicsclerosis,systemiclupuserythematosus
Thereisnorelevanceofhistoryofalcoholabuse(OptionA)isincorrect.AlcoholabuseisassociatedwithDCM.
Afamilyhistoryofasimilarproblemisunrelated(OptionB)isincorrect.DCMisfamilial(autosomaldominant)inat
least20%ofcases.
Viralillnessinthepastisunrelated(OptionD)isincorrect.Viralillness(e.g.coxsackievirusorHIV)isassociatedwith
DCM.
Historyofpulmonarytuberculosisinthepastisrelevant(OptionE)isincorrect.Aconstrictivepericarditisismore
commonlyseenwithTB,ratherthanaDCM.
41865
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Question269of295
A42yearoldman,knowntobehypertensive,ranoutofhismedication2daysago.HepresentedtotheEmergency
Departmentfeelingshortofbreathanddizzy.Hisbloodpressureonadmissionwas230/140mmHg.Fundoscopyshowed
blurreddiscmargins.Hischestrevealedbibasalcrepitations.
Withtherapy,whatbloodpressureshouldyouaimforinthenext1hourinsuchcases?
A <130/80mmHg
B <140/90mmHg
C Decreaseinmeanarterialpressure(MAP)by4050%
D DecreaseinMAPby1525%
E DecreaseinMAPby6070%
Explanation
TheanswerisDecreaseinMAPby1525%
Thispatientpresentswithahypertensiveemergencyabloodpressure>180/120mmHgwithprogressivetarget
organdamage.TheaimistoreducetheBPinacontrolledmannerwithclosemonitoringtargetinga25%inthe
MAP(optionD)inthefirstinstance.
Greaterreductionsthanthisinthefirsthourriskorganhypoperfusionduetoadysfunctionintissueautoregulation.
Hypertensiveemergency
Thepatienthasahypertensiveemergencywithmarkedlyelevatedbloodpressureandevidenceoftargetorgan
damagethissituationrequiresimmediateattentiontopreventdisabilityordeath
Here,theaimistoreducethebloodpressurepromptlybutpartially,topreventendorgandamagewithout
compromisingtissueperfusion
Theinitialtargetistolowerthemeanarterialpressure(MAP)bynomorethan25%,orreducethediastolicblood
pressurebyonethird
MAP=diastolicbloodpressure+[(systolicbloodpressurediastolicbloodpressure)/3]
Eveninthepresenceofheartfailureorhypertensiveencephalopathy,acontrolledreduction,toalevelofabout
150/90mmHg,overaperiodof2436hours,isideal
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Inmostpatients,bloodpressurecanbebroughtdownwithbedrestandoralmedication
Intravenouslabetalol(2mg/mintoamaximumof200mg),intravenousglyceryltrinitrate(0.61.2mg/h),
intravenoussodiumnitroprusside(0.31.0mg/kgpermin)andintramuscularhydralazine(5or10mgrepeatedat
halfhourlyintervals)arealleffectivebutrequireclosemonitoring
<130/80mmHg(OptionA)isincorrect.Reductionsgreaterthan25%intheMAPinthefirsthourriskorgan
hypoperfusionduetoadysfunctionintissueautoregulation.
<140/90mmHg(OptionB)isincorrect.Reductionsgreaterthan25%intheMAPinthefirsthourriskorgan
hypoperfusionduetoadysfunctionintissueautoregulation.
DecreaseinMAPby4050%(OptionC)isincorrect.Reductionsgreaterthan25%intheMAPinthefirsthourriskorgan
hypoperfusionduetoadysfunctionintissueautoregulation.
DecreaseinMAPby6070%(OptionE)isincorrect.Reductionsgreaterthan25%intheMAPinthefirsthourriskorgan
hypoperfusionduetoadysfunctionintissueautoregulation.
41878
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Question270of295
A62yearoldmanwithtwopreviousmyocardialinfarctionsandahistoryofleftventricularfailurecontrolledwith
ramiprilandfurosemidepresentstohisGPwithpalpitations.OnexaminationhisBPis100/72mmHg,pulse95bpmatrial
fibrillation(AF),withbibasalcracklesconsistentwithheartfailure.Clinicalresultsaregiveninthetablebelow:
Hb 12.1g/dl
WCC 5.4109/l
PLT 234109/l
Na+ 140mmol/l
K+ 5.0mmol/l
Creatinine 130mol/l
Echo dilatedleftatriumandleftventricle
WhichoneofthefollowingwouldbethemostappropriateagenttocontrolhisAF?
A Diltiazem
B Sotalol
C Amiodarone
D Digoxin
E Verapamil
Explanation
Controlofatrialfibrillation
Verapamil,diltiazemandsotalolarealltoagreaterorlesserextentnegativelyinotropicandmayworsencardiac
failure
Giventhatthepatientssystolicbloodpressureisonly100,anyfurtherreductionincardiacoutputislikelyto
furtherworsenhisBP
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Amiodaroneisusefulforchemicalcardioversionandassuchisnotthebestchoicehere
Digoxinislessusefulforratecontrolinatrialfibrillation(AF)thancalciumantagonistsorblockers,butisthe
mostappropriatechoicehereasitdoesimprovesymptomsinpatientswithcardiacfailureand,giventheenlarged
leftatrium,successfulcardioversionisunlikely
20454
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Question271of295
A70yearoldman,previouslyfitandwell,isreferredtooutpatientswithexertionalchestpainthatcomesonataround
0.8km(0.5mile)ontheflat.Examinationrevealshimtobeinsinusrhythmat80bpm,bloodpressure100/70mmHg,a
diminishedcarotidupstrokeandaloudejectionsystolicmurmurovertheaorticarea.Echoconfirmsleftventricular
hypertrophy,preservedsystolicfunctionwithpeakaorticvalvegradientsof80mmHg.Subsequentcoronaryangiography
revealssignificantdiseaseintheleftanteriordescendingartery.
Whatistheoptimaltreatmentstrategy?
A Angioplastyandstentingtotheleftanteriordescendingartery
B Aorticvalvereplacementandbypassgraft
C Aspirinandreviewin3monthstimewitharepeatecho
D Aspirinandablocker,andreviewin3monthstimewitharepeatecho
E Percutaneousaorticvalvotomy
Explanation
Aorticstenosis
Thispatienthassevere(aorticvalvegradient>70mmHg),symptomaticaorticstenosisandassuchvalve
replacementisindicated,unlessprecludedbycomorbidity
Coronaryangiographyisperformedtoassesstheneedforconcomitantcoronaryarterybypassgrafting
Developmentofsymptoms
Withacquiredaorticstenosis,patientsmostcommonlypresentintheirsixthdecadewithsymptomsofangina,
syncopeorheartfailure
Thedevelopmentofsymptomsisassociatedwithapooroutcomeifleftuntreated
Theaveragelifeexpectancyfromtheonsetofsymptomstodeathis2yearsinpatientswithheartfailure,3years
inthosewithsyncopeand5yearsinthosewithangina
1371
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Question272of295
A42yearoldpatientwhohasahistoryofparoxysmalatrialfibrillation(AF)hasbeentreatedwithwarfarin.TheAFhas
nowresolvedaftersuccessfulDCcardioversion.Clinicalresultsaregiveninthetablebelow:
Hb 13.1g/dl
WCC 4.9109/l
PLT 294109/l
Na+ 139mmol/l
K+ 4.8mmol/l
Creatinine 100mol/l
TSH 2.1U/l
Echo normalsizedleftatrium,nosignificantvalvulardisease
Forhowlongshouldthewarfarinbecontinued?
A 4weeks
B 6months
C 1year
D 3years
E Stopwithimmediateeffect
Explanation
Warfarinandatrialfibrillation
Thispatienthasbenignfindingsonechocardiography,withnormalleftatrialsize
Itisthereforelikelythathehasareasonablechanceofremaininginsinusrhythm
Whilstthereisnospecificdurationofanticoagulationrecommendedinthe2014NICEguidance,itstillseems
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prudenttocontinuetherapyfor4weeks
Wheretheriskofrecurrenceishigh,ortherearemultiplefailedcardioversions,longtermwarfarintherapyis
advised
20717
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Question273of295
A67yearoldmanisreferredtothecardiologyclinicwithangina,progressiveheartfailureandtwoepisodesofsyncope.
Hehasahistoryofhypertensionmanagedwithramiprilandindapamide,andsufferedaninferiormyocardialinfarction
some4yearsago.OnexaminationhisBPis125/105mmHg,andhehasasoftejectionsystolicmurmurloudestatthe
rightsecondintercostalspace.HehasevidenceofLVHandtherearebilateralinspiratorycracklesonauscultationofthe
chestconsistentwithLVF.Thetablebelowshowstheinvestigationresults.
Hb 12.4g/dl
WCC 6.1109/litre
PLT 208109/litre
Na+ 140mmol/litre
K+ 4.3mmol/litre
Creatinine 185mol/litre
Whichoneofthefollowingislikelytobethemostsignificantproblemdrivinghissymptoms?
A Coronaryarterydisease
B Mitralregurgitation
C Aorticstenosis
D Cardiacarrhythmias
E Chronicrenalfailure
Explanation
Aorticstenosis
Thetriadofangina,leftventricularfailureandsyncopeisclassicalwithrespecttoaorticstenosis
Confoundingfactors
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Twoconfoundersexist
intheelderlythemorehighfrequencycomponentsofaorticstenosismaybeheardbestattheapex,theso
calledGallavardinphenomenon
andthecomponentsofthemurmurmaybesoftenedinsituationswherecardiacoutputisreduced
Management
Giventhismanhasevidenceofcoronaryarterydiseasehemaywellhavecoexistentreducedcardiacoutput
Henceherequiresassessmentofbothaorticvalveandcoronaryarterystatus,withcombinedvalvereplacement
andcoronaryarterybypassgraftsurgerylikelytobethemostappropriatewaytomanagehim
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Question274of295
A32yearoldmanwithWolffParkinsonWhitesyndromepresentswitha2hourhistoryofpalpitationsand
breathlessnesstoA&E.Onexamination,hisheartrateis190bpmwithbloodpressureof90/60mmHg.ECGshowsan
irregularbroadcomplextachycardia.
Whatwouldbeyourfirstlineoftreatment?
A Intravenousamiodarone
B Intravenousflecainide
C Intravenousadenosine
D DCcardioversion
E Intravenousverapamil
Explanation
TheanswerisDCcardioversion
Thepatienthaspreexcitedatrialfibrillationwithfeaturesofhaemodynamiccompromise(90/60mmHg).Therefore,
thebestoptionistoperformDCcardioversionwithanaestheticcover.
Intravenousamiodarone(OptionA)isincorrect.AmiodaroneisrecommendedbytheAHA/ACLSinpatientswhoare
stablewithpreexcitedAF,butthispatienthasfeaturesofhaemodynamiccompromiseandsothisisnotthepreferred
option.
Intravenousflecainide(OptionB)isincorrect.Flecainide,orprocainamide,isapotentialoption,butshouldonlybeused
byaspecialistcardiologistinthissituation.
Intravenousadenosine(OptionC)isincorrect.AVnodalblockingagentssuchasadenosinearecontraindicatedin
patientswithpreexcitedatrialfibrillationasitwillpromotetheconductionoftheAFviatheaccessorypathway,leadingto
anaccelerationoftherhythmorconversiontoVF.
Intravenousverapamil(OptionE)isincorrect.AVnodalblockingagentssuchasverapamilarecontraindicatedinpatients
withpreexcitedatrialfibrillationasitwillpromotetheconductionoftheAFviatheaccessorypathway,leadingtoan
accelerationoftherhythmorconversiontoVF.
41908
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Question275of295
Inanasymptomaticpatient,apermanentpacemakerisindicatedinwhichoneofthefollowingconditions?
A FirstdegreeblockattheAVnode
B FirstdegreeblockinthedistalconductionsystemwithanHVinterval<100ms
C SeconddegreeblockattheAVnode
D Seconddegreeblockatthedistalconductionsystem
E Rightbundlebranchblock
Explanation
Permanentpacemakerinasymptomaticpatient
Inanasymptomaticpatient,apermanentpacemaker(PPM)isindicatedinsecondandthirddegreeheartblockat
thedistalconductionsystem
Ifthethirddegreeblockattheatrioventricular(AV)nodehadbeenassociatedwithsymptoms,itwouldhavebeen
anindicationforPPM
Also,aPPMisindicatedforcasesoffirstdegreeAVblockinthedistalconductionsystemwithanHV(Bundleof
Histoventriculardepolarisation)intervalofgreaterthan100msassociatedwithsymptoms
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Question276of295
A62yearoldmanwithahistoryofCKD4renalimpairmentisadmittedtotheEmergencyDepartmentafteraprolonged
episodeofgastroenteritis.Hiswifeproudlytellsyouthatevenwhilsthehasbeenunwellshehascontinuedtogivehimhis
diureticsandLisinopril.OnexaminationhisBPis90/60mmHg,pulseis90/minandregular.Helooksverydehydrated.
Youarrangeurgentinvestigations,theresultsofwhichareshownbelow:
pH 7.21
K+ 7.2mmol/l
Na+ 139mmol/l
Bicarbonate 15mmol/l
Creatinine 585micromol/l
Urea 23.1mmol/l
Whichofthefollowingwouldyouexpecttoseeonthe12leadECG?
A InvertedPwaves
B Jwaves
C PeakedTwaves
D STdepression
E Uwaves
Explanation
TheanswerisPeakedTwaves
Hyperkalaemiaisassociatedwith:
PeakedTwaves
ProlongationofthePRinterval
WideningoftheQRS
ReducedorlossofthePwave
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SeverehyperkalaemiaisassociatedwithasinewavepatternontheECGandultimatelyasystoleiftreatmentisnot
instigated.InthissituationurgenttreatmentwouldincludeIVcalciumundercardiacmonitoring,IVinsulinanddextrose,
andpotentiallynebulisedbetaagonists.
InvertedPwavesareassociatedwithabnormalatrialconduction,Jwaveswithhypothermia.STdepressionandUwaves
areseeninpatientswithhypokalaemia.
37285
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Question277of295
A36yearoldwomanpresentswithacerebralinfarctfollowingtreatmentforadeepveinthrombosis.Cardiovascular
examinationisentirelynormal.
Whatisthemostlikelyunderlyingcardiacabnormality?
A Commonatrium
B Ostiumprimumatrialseptaldefect
C Ostiumsecundum
D Partialanomalouspulmonaryvenousdrainage
E Patentforamenovale
Explanation
TheanswerisPatentforamenovale(PFO)
Patentforamenovale
Theclinicalscenariodescribesaparadoxicalembolusthatisonewhichhastravelledfromthevenoussysteminto
thearterialcirculation.Forthistooccur,theremustbeashuntofsomekind.
Toanswerthisquestion,youshouldbeawarethatPFOsareverycommonanditismuchmorecommonthanthe
otherconditionslisted.Estimatessuggest1in4peoplehaveaPFOpresent.Theshuntisnotopenthemajorityofthe
timeitismerelyapotentialspace.Whenrightatrialpressureexceedsleftatrialpressureitwillopenandallow
venousdebristoenterthearterialcirculation.Thisistypicallyduringvalsalvasuchasstrainingatstool,childbirth
andduringdiving.
YoushouldalsobeawarethatPFOhasnofindingsonroutineclinicalexaminationasisthecaseinthepatientin
thequestion.Incontrast,alltheotherpotentialanswersoftenhaveclinicalfindings.
PFOsrequirevalsalvaduringanechocardiographicexaminationwithagitatedsalinetobestvisualisethemonce
thesalineisgivenintoavein,bubblescanbeseenfillingtherightatrium.ValsalvawillcausethePFOtoopenand
(evenifthatcannotbeseen)bubblesmaybeseenenteringtheleftatrium.
InASD,whetherprimum(lesscommon)orsecundum(morecommon),patientswillhavefixedsplittingofthe
secondheartsound,mayhaveanejectionsystolicmurmurofincreasedbloodflowacrossthepulmonaryvalveand
willhaveRBBBonECG.
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Commonatrium(OptionA)isincorrect.Asdescribednormalclinicalexaminationwouldbeunusual.
Ostiumprimumatrialseptaldefect(ASD)(OptionB)isincorrect.Asdescribednormalclinicalexaminationwouldbe
unusual.
Ostiumsecundum(OptionC)isincorrect.Asdescribednormalclinicalexaminationwouldbeunusual.
Partialanomalouspulmonaryvenousdrainage(OptionD)isincorrect.Partialanomalouspulmonaryvenousdrainage
(optionA)meansthatbetweenoneandthreepulmonaryveinsopenintotherightatriumratherthantheleftatriumthere
isnoincreasedriskofrighttoleftshunting.Instead,thesepatientsmaybecyanosedandclubbed.
41999
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Question278of295
A38yearoldwomanisseenintheEmergencyDepartmentwithahistoryofcollapse.Sherecallsrushingforthebus
beforefeelingfaint.Herbrotherrecentlydiedsuddenlyowingtoaheartproblem.Onexaminationshehasajerkypulse,
athrustingcardiacimpulseandamidsystolicmurmur.
Whichoneofthefollowingisthelikelydiagnosis?
A Dilatedcardiomyopathy
B Hypertrophicobstructivecardiomyopathy
C Mitralvalveprolapse
D Aorticstenosis
E Pericarditis
Explanation
TheanswerisHypertrophicobstructivecardiomyopathy(HOCM)
Theageofthepatient(38)andherfamilyhistory(abrotherwhodiedsuddenlyasaresultofaheartproblem)make
HOCMthelikelydiagnosis.
Hypertrophicobstructivecardiomyopathy(HOCM)
HOCMisthecommonestformofcardiomyopathy,withaprevalenceofabout100per100000
Itisageneticdisorderwithautosomaldominanttransmission,ahighdegreeofpenetranceandvariableexpression
Symptomsandsigns
Symptomsandsignsaresimilartothoseofaorticstenosis,exceptthatthecharacterofthepulseinHOCMisjerky
WithValsalvatheintensityofthemurmurincreaseswithHOCM,butdecreasesinaorticstenosis
SuddendeathcanbeapresentingsymptomofHOCM
Ittypicallyoccursduringorjustaftervigorousphysicalactivity
Riskfactorsforsuddendeath
RiskfactorsforsuddendeathinHOCMare:
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ahistoryofpreviouscardiacarrestorsustainedventriculartachycardia
recurrentsyncope
anadversegenotypeand/orfamilyhistory
exerciseinducedhypotension
multipleepisodesofnonsustainedventriculartachycardiaonambulatoryECG
amarkedincreaseinthethicknessoftheleftventricularwall
PatientswithanadverseriskprofilemayreceiveanICDforprimaryprophylaxis
PatientswithHOCMwhohavehadabortedsuddendeath,orwhohaveevidenceofrecurrentventricular
tachycardiaonHoltermonitoring,mayalsoreceiveanICD
Dilatedcardiomyopathy(OptionA)isincorrect.Dilatedcardiomyopathyisnotassociatedwiththefeaturesoftheclinical
examination(thrustingcardiacimpulse,andmidsystolicmurmur).
Mitralvalveprolapse(OptionC)isincorrect.Mitralvalveprolapsedisnotassociatedwiththefeaturesoftheclinical
examination(thrustingcardiacimpulse,andmidsystolicmurmur).
Aorticstenosis(OptionD)isincorrect.ThepresenceofajerkypulseisverytypicalofHOCMratherthanaortic
stenosisthepulseisslowrisinginaorticstenosisandthereforethisisnotthecorrectanswer.
Pericarditis(OptionE)isincorrect.Pericarditisisnotassociatedwiththefeaturesoftheclinicalexamination(thrusting
cardiacimpulse,andmidsystolicmurmur).
41875
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Question279of295
A60yearoldCaucasianman,withNYHA(NewYorkHeartAssociation)classIIheartfailure,istakinganangiotensin
convertingenzyme(ACE)inhibitorsandbisoprololforhisheartfailure.Heisalsotaking50mgoffurosemide.Heis
generallywellinhimself.Ondirectquestioningathisroutineoutpatientvisit,hehasnoticedaseveredeteriorationinhis
exercisetoleranceoverthelastyearandhenowsleepsinachairdownstairsbecausehefindsitimpossibletoclimbthe
stairsowingtoshortnessofbreath.Examinationrevealsabloodpressureof105/72mmHg,pulseof85/minandregular.
Therearebilateralbasalcracklesonauscultationofthechest,andbilateralankleswelling.
Whichoneofthefollowingdrugsshouldbeaddedtohislistofmedicationswithrespecttohisoverallprognosis?
A Digoxin
B Bumetanide
C Isosorbidemononitrate
D Spironolactone
E Valsartan
Explanation
TheanswerisSpironolactone
TheEuropeanSocietyofCardiologyrecommendstheadditionofspironolactoneforimprovingthesurvivalof
patientswhoareinthetransitionfromwellcontrolledclassIItoclassIIIorIVheartfailurethemortalitybenefitis
considerable.GiventhatthepatientishavingaworseningofsymptomsdespiteACEIandblocker,spironolactone
isthenextmostappropriatetherapyforprognosis.
Digoxin(OptionA)isincorrect.Digoxinhelpstorelievesymptomstosomeextent,andismoreusefulifthepatientisin
atrialfibrillationhowever,thereisnoovertprognosticbenefitwithdigoxinandthereforeitisnotthecorrectanswer.
Bumetanide(OptionB)isincorrect.Diureticsareonlyindicatedifthereisfluidretentionandareassociatedwithaworse
prognosisoverallitisrecommendedthattheyarestoppedifitissafetodosowhenthepatientiseuvolaemic.
Isosorbidemononitrate(OptionC)isincorrect.Nitratesandhydralazineincombinationhelptoimprovesymptomsin
patientswithclassIIIandIVheartfailure.
Valsartan(OptionE)isincorrect.CombinationsofACEinhibitorsandangiotensinreceptorblockersarenolonger
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recommendedinthemajorityofpatientsashyperkalaemia,hypotensionandimpairedrenalfunctionaremorelikely.
TherearesomedatathatACEinhibitorsandARBstogetherimproveprognosisforaselectgroupofheartfailurepatients,
butsafetyconcernsremain.
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Question280of295
Youarereviewingthemodeofactionofagentsthatexerttheiractionviathecardiacactionpotential.
Whichofthefollowinghappensinphase3ofthecardiacactionpotential?
A Ca2+Lchannelsclose
B Ca2+Ichannelsclose
C Chloridechannelsclose
D Fastsodiumchannelsclose
E SlowdelayedrectifierK+channelsclose
Explanation
TheanswerisCa2+Lchannelsclose
CalciumLchannelsareopeninphase2ofthecardiacactionpotential,andcloseinphase3oftheactionpotential.
VerapamilisanexampleofacalciumLchannelblocker.IvabradineactsonthecalciumIf(funny)channelandisusedas
atreatmentforcardiacfailureandanginawherethepulserateiselevated.Inactivationoffastsodiumchannelsoccursin
phase1oftheactionpotential.MutationsinthesodiumchannelareresponsibleforBrugadasyndrome.Slowdelayed
rectifierK+channelsopeninphase2and3ofthecardiacactionpotential.
NerbonneJM,KassRS.Molecularphysiologyofcardiacrepolarization.Physiol.Rev.85,12051253(2005)
40229
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Question281of295
A36yearoldmanisadmittedtotheEmergencyDepartmentwithcentralcrushingchestpain,sweating,tachycardiaand
anxiety.Headmitstoheavyuseofcocaineandsmokes30cigarettesperday.OnexaminationhisBPis165/85mmHg,
pulseis95/minandregular.HisECGshowsanterolateralSTdepression.
A6hrtroponiniselevatedat3.1microg/l
Howwouldyouclassifyhismyocardialinfarction?
A Type1
B Type2
C Type3
D Type4
E Type5
Explanation
TheanswerisType2
TheuniversaldefinitionofMIsubclassifiedMItypesin2012.ThiswouldfittheclassificationforaType2MI,
myocardialinfarctionsecondarytoanischaemicimbalance,(i.e.inthiscaserelatedtoseverevasospasmbecauseofthe
cocaineabuse).
OthertypesofMIarelistedbelow:
Type1:SpontaneousMI
Type3:DeathduetoMI
Types4and5:MIduetoaprocedure
http://www.escardio.org/Guidelines&Education/ClinicalPracticeGuidelines/ThirdUniversalDefinitionofMyocardial
Infarction(http://www.escardio.org/Guidelines&Education/ClinicalPracticeGuidelines/ThirdUniversalDefinitionof
MyocardialInfarction)
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Question282of295
A55yearoldmanwithahistoryofmitralregurgitationandatrialfibrillationiswarfarinised.HisINRistherapeuticat
2.0.Heneedstoundergopreplannedtoothextractionunderlocalanaesthesia.Howwouldyoumanagehimbeforethe
procedure?
A Stopwarfarinfor2days
B Stopwarfarin,startLMWH
C Stopwarfarin,startunfractionatedheparin
D Stopwarfarinstartaspirin
E Maintainwarfarinatthetherapeuticdose
Explanation
Surgicaltreatmentduringwarfarintherapy
Forpatientsonshorttermwarfarintreatmentitisrecommendedthatpatientswaitfortreatmentuntilafterthey
havediscontinuedtheirperiodofwarfarintherapy
Forthoseonlongtermwarfarintherapy,BritishHaematologicalSocietyguidelinessuggestthataslongasthe
internationalnormalisedratio(INR)isnotabove2.0,theproceduremaytakeplaceinthestandardway
UKMedicinesInformation(UKMI)recommendationsaremorerelaxed,suggestingthatdentalproceduresmay
takeplaceaslongastheINRislessthan4.0
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Question283of295
Whichoneofthefollowingstatementsistrueofraisedcardiactroponinlevelsintheblood?
A ArecommonlyseentolevelsabovethatforMIdiagnosisafterDCcardioversion
B Remainelevatedforupto2daysaftermyocardialdamage
C AreseeninpatientswithNSTEMI
D CanbeusedtodistinguishnonQfromQMI
E Areonlyseenincardiacconditions
Explanation
TheanswerisAreseeninpatientswithNSTEMI
Cardiactroponins
ThemostsensitivemarkersofmyocardialcelldamagearethecardiactroponinsTandI
Troponinsareregulatoryelementsofthecontractileapparatusinmuscle
Theyarereleasedwithin46hoursofmyocardialcelldamage,andremainelevatedforupto2weeks
UnstableanginaandSTsegmentmyocardialinfarctionaredifferentendsofthespectrumofmyocardialdamage
typicallyinunstableangina,thereisnotroponinrise.TrueSTEMIwillhaveveryhighlevelsoftroponinthelevelof
troponinactsasaprognosticmarker,withveryhighlevelssuggestiveofapoorerprognosis
AnginaassociatedwithatroponinriseisessentiallyanNSTEMIoracutecoronarysyndrome
NonQandQmyocardialinfarctionarediagnosedusingECGbothhaveraisedtroponinlevelsandtherefore
cannotbeusedtodistinguishbetweennonQandQwaveinfarcts
Indicationsofraisedtroponinlevels
Raisedtroponinlevelsindicateheartmuscledamage:thecommonestcausebeingmyocardialischaemia
Myocarditisormyocardialcontusioncanalsocauseraisedtroponinlevels,egfromblunttraumasustainedafteran
MI
Troponinisalsoraisedbythefollowingcardiacconditions:
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Trueacutecoronarysyndrome:plaquerupture
Coronaryvasospasm(vesselsqueezing)
Severetachycardia,egSVT
Heartfailure:constantlowleak,worseindecompensation
Cardiomyopathies
Pericarditis
Cocaine
Athletesandendurancerunners
Troponin,althoughveryspecifictocardiactissue,canberaisedinavarietyofconditionsthatarenotprimarily
cardiac.Thefollowingillnessstatescancausetroponinrise:
CriticalIllness
ITU/Sepsis
Hypotension
Hypertensivecrisis/preeclampsia
PE
InfectiveexacerbationsofCOPD
AAA
Gastrointestinalbleeding
Chemotherapy
Renalimpairment
ArecommonlyseentolevelsabovethatforMIdiagnosisafterDCcardioversion(OptionA)isincorrect.Cardioversion
cangiverisetoraisedcreatinekinase(CK)levelsowingtoskeletalmuscledamage
Remainelevatedforuptotwo2daysaftermyocardialdamage(OptionB)isincorrect.Asdescribedtheymayremain
raisedforupto2weeks.
CanbeusedtodistinguishnonQfromQMI(OptionD)isincorrect.Asdescribedbothwillhaveraisedtroponinlevelsso
thiscannotbeusedtodistinguishbetweenthetwo.
Areonlyseenincardiacconditions(OptionE)isincorrect.Asdescribedtroponinrisesmaybecausedbyanumberof
conditions.
41859
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Question284of295
A25yearoldmanwasfoundbyhisfamilyathomehavingsufferedacardiacarrest.Hewaspreviouslywell,apartfrom
wellcontrolledtype1diabetescontrolledwithabasalbolusinsulinregime.Hisfamilyfollowedtheambulanceandaskif
theycanbeintheresuscitationroom.After20minofrepeatedresuscitationcycles,hehasremainedinasystole.Thetable
belowgivestheresultsofbloodgasanalyses:
pH 7.01
PO2 8.4kPa
PCO2 3.9kPa
Bicarb 10mmol/l
Whichoneofthefollowingisthemostappropriatepersontomakethedecisiontodiscontinueresuscitation?
A EmergencyDepartmentconsultant
B Oncallmedicalconsultant
C Parentsofthepatient
D Patientsfiance
E Resuscitationteamleader
Explanation
Resuscitationdecisions
Clear,appropriatecommunicationisakeycomponentofresuscitation
Althoughitmaybeappropriatetoallowthepresenceofrelativeswithintheresuscitationroom,theydonothave
theauthoritytocontinueordiscontinueresuscitation,althoughtheydoneedtobeinformedofprogress
AlthoughtheexperienceoftheEmergencyDepartmentoroncallmedicalconsultantsmaybeusefulingaining
advice,theresuscitationteamleaderisusuallyasenioranaesthetistorphysicianintheirownright,andqualified
todecideondiscontinuingresuscitation
Ifthereisanydoubt,theresuscitationteamleadercandiscussthesituationwiththeconsultantoncall
18560
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Question285of295
A38yearoldmanpresentsforreview.Hisonlyprevioushistoryofnotehasbeenrecurrentshouldersubluxation.His
maincomplaintsaretirednessandincreasingdyspnoeaonexertion.Thenursingclerkonadmissionnotesthatheseems
verytallandthin,hisheightisdescribedas1.93m(6ft4in).Onexaminationhisbloodpressureis170/70mmHg,hehas
leftventricularhypertrophy,alowpitcheddiastolicmurmuratthelowersternaledgeandanearlysystolicejection
murmuratthesecondintercostalspaceontheright.
Whatdiagnosisfitsbestwiththisclinicalpicture?
A Aorticregurgitation
B Aorticstenosis
C Infectiveendocarditis
D Mitralstenosis
E Mitralvalveprolapse
Explanation
TheanswerisAorticregurgitation
Thispatienthasamarfanoidhabitusandisatriskofsufferingaorticregurgitationormitralvalveprolapsebothof
whichareverycommoninMarfansyndrome.Thepresenceofadiastolicmurmuratthelowersternaledge,together
withawidepulsepressure,isstronglysuggestiveofaorticregurgitation.Theconcomitantejectionsystolicmurmur
iscommoninpatientswithaorticregurgitationsincetheincreasedLVvolumewitheachheartbeat(dueto
regurgitation)causesincreasedturbulenceduringsystolicejection.
Aorticregurgitation
Aetiology
Aetiologicalfactorsinvolvedinaorticregurgitationinclude
infectiveendocarditis
rheumaticheartdisease
traumawithvalvularrupture
congenitalbicuspidaorticvalve
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myxomatousdegeneration
syphiliticaortitis
systemiclupuserythematosus
aorticdissection
useofamphetamineslimmingproducts.
InMarfanthereisaorticrootdilatationduetotheabnormalconnectivetissuewhichleadstoafailureofleaflet
coaptationandregurgitation.
Symptoms
Ingeneral,aorticregurgitationiswelltolerateduntilitissevere,whereuponthereisprogressivedilatationofthe
LVandexertionalsymptoms.
Symptomsofaorticregurgitationinclude
dyspnoeaonexertion
syncope
chestpain
congestiveheartfailure.
Investigationfindings
Cardiacauscultationcharacteristicallyrevealsdisplacementofthecardiacimpulsedownwardsandtotheleft,
prominentS3heardovertheapex,alowpitchedapicaldiastolicrumble(AustinFlintmurmur)andanearlysystolic
apicalejectionmurmur.
ChestXraymayrevealleftventricularhypertrophyandaorticdilatation.
Echocardiographyrevealsthecoarsediastolicflutteringoftheanteriormitralvalveleaflet.
Treatment
Patientsshouldbegivendiureticsifthereisfluidoverloadduetoventriculardilatation.
Avoidblockersinaorticregurgitationsinceaprolongeddiastolicphase(astheheartrateisslower)willworsen
theregurgitantfraction.
Reducingtheafterload(iethebloodpressure)mayreducethedegreeofregurgitantfractionACEinhibitorsand
angiotensinreceptorblockersarehelpfulinhypertensivepatientsinreducingtheregurgitantfraction,butmayhave
littlebenefitinnormotensivepatients.
Surgicalvalvereplacementisindicatedinsymptomaticpatientswithchronicaorticregurgitationwhohave
symptomsdespiteoptimalmedicalmanagement,andinacuteaorticregurgitationwherethereisevidenceofleft
ventricularfailure.
Ideally,surgeryshouldbeconsideredbeforetheejectionfractionfallstobelow55%ortheleftventricular
dimensionsexceed55mminendsystole(thatiswhentheventricleisatitssmallest).
Aorticstenosis(OptionB)isincorrect.Aorticstenosisexpectedfindings:aharshcrescendodecrescendoejectionsystolic
murmuratthesecondintercostalspaceontheleft,radiatingintotheneck.
Infectiveendocarditis(OptionC)isincorrect.Infectiveendocarditiscouldaffectanyvalveleadingtoregurgitation.There
arenoconstitutionalsymptoms(fevers,weightloss,malaise)inthiscase,orperipheralstigmata(Oslersnodes,Janeway
lesions,splinterhaemorrhages,haematuria).
Mitralstenosis(OptionD)isincorrect.Mitralstenosisexpectedfindings:diastolicrumbleattheapex,oftenwithatrial
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fibrillation.
Mitralvalveprolapse(OptionE)isincorrect.Mitralvalveprolapseexpectedfindings:midsystolicejectionclickwitha
pansystolicmurmurattheapexthatisaccentuatedbystandingfromasquattingpositionorstraining.
42010
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Question286of295
AsmedicalregistraroncallyouaresummonedtoassistwithacardiacarrestonCCU.A60yearoldmanisbeing
resuscitatedhavingpresentedwithunstableangina3daysbefore.Hehashadthreeunsuccessfulshocksforventricular
fibrillation.Ananaesthetistislookingafterhisairway.Hehasalargeboreivaccessinhisantecubitalfossa.
Whatadditionaltherapywouldyouconsideratthispoint?
A Amiodarone
B Bretylium
C Calciumchloride
D Lidocaine
E Sodiumbicarbonate
Explanation
Therapyduringcardiacarrest
CurrentrecommendationsforadvancedlifesupportintheUKareprovidedbytheEuropeanResuscitation
CouncilandtheResuscitationCouncilUK
Inpatientswithrefractoryventricularfibrillationorpulselessventriculartachycardia(ieafterthreeinitialshocks),
intravenousamiodaroneshouldbeconsidered
Thestandarddoseusedisa300mgbolus
Ifcentralaccessisavailablethisisthedesiredroute
However,ifthisisnotthecasethenalargeboreperipheralaccesscanbeused
Lidocaine(lignocaine)isusedwhenamiodaroneisunavailable
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Question287of295
Fora20yearoldmanwhohassurvivedanoutofhospital(VF)cardiacarrest,whichoneofthefollowingislikelytobe
themostappropriatetreatment?
A Amiodarone
B Betablocker
C Dualchamberpacemaker
D Implantedcardioverterdefibrillator
E Verapamil
Explanation
TheanswerisImplantedcardioverterdefibrillator
Outofhospitalventricularfibrillation
Patientswhohaveanoutofhospitalventricularfibrillation(VF)arrestshouldundergoinvestigationto
discoverifthearrestwascausedbyinfarction/ischaemiaorbyachronicelectrophysiologicalinstability.
30%ofpatientswillhavearecurrencewithin1year,risingto60%at2years.
Treatment
Inthiscase,atsuchayoungage,aproarrhythmicstate(suchasduetocardiomyopathy,longQTsyndrome,
Brugadasyndrome,etc)ismorelikelythanischaemiaandanimplantablecardioverterdefibrillator(ICD)is
themostappropriatetreatment.
ItisessentialtoexcludeclearprecipitantssuchasdrugoverdoseorcocaineingestionbeforeICD
implantation.
VTablationmaybeappropriateinpatientswithdefiniteVT.
Amiodarone(OptionA)isincorrect.Amiodaroneisusedinthetreatmentandprophylaxisofventricularand
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supraventriculararrhythmias.ItmaybepossiblethatthepatientrequiresamiodaroneinadditiontoICD.Inyoung
patients,amiodaroneisavoidedduetoitsmanysideeffectsandpotentialforlungfibrosiswithprolongeduse.
Betablocker(OptionB)isincorrect.Ablockerisofuseifischaemiaisthecause.
Dualchamberpacemaker(OptionC)isincorrect.Dualchamberpacemakerisusuallyreservedforpatientswith
symptomaticbradycardiabradycardiaandpausescancausecollapsebutthehistoryhereclearlystatesVFarrest,sothisis
notappropriate.
Verapamil(OptionE)isincorrect.Verapamilmaybeusedinthetreatmentofsupraventriculartachycardia.
42036
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Question288of295
A35yearoldwomanpresentswithahistoryofintermittentlightheadedness.Clinicalexaminationand12leadECGare
normal.
Whichoneofthefollowing,ifpresentona24hHolterECGtracing,wouldbethemostclinicallyimportant?
A Atrialprematurebeats
B Heartratesof40bpmduringsleep
C Supraventriculartachycardia
D TransientMobitztype1atrioventricularblock
E Ventricularprematurebeats
Explanation
TheanswerisSupraventriculartachycardia
Supraventriculartachycardia
AlltheanswerslistedarecommonfindingsonHoltermonitors.
Inthiscase,giventhepresentationofintermittentlightheadednessthensupraventriculartachycardia(SVT)
carriesthemostclinicalsignificance.
DiagnosisoftheunderlyingcauseoftheSVTwillbebasedonthepresenceorabsenceofPwavesandPwave
morphology.
PatientscanbetaughtvalsalvaexercisesorcarotidsinusmassagetoavertSVTsathome.Thosewhopresentinthe
EmergencyDepartmentshouldbegivenadenosineforacutecardioversiontosinusrhythm.
Longertermmanagementmayrequireblockerstosuppressepisodes.Flecainideorsotalolmayalsobe
consideredforprophylaxis.
Atrialprematurebeats(OptionA)isincorrect.Atrialprematurebeatsarecommonandtypicallyconsiderednormalwhen
theburdenofeventsislow.
Heartratesof40bpmduringsleep(OptionB)isincorrect.Profoundbradycardiamayalsooccurduringsleepandisa
normalfindingcertainlyitdoesnotreflecthersymptoms.
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TransientMobitztype1atrioventricularblock(OptionD)isincorrect.Mobitztype1atrioventricularblockcarriesless
clinicalsignificancethanMobitztype2,becausetheriskofprogressiontocompleteheartblockismuchloweritisalsoa
commonfindingatnightinyoungpeoplewithelevatedvagaltone.
Ventricularprematurebeats(OptionE)isincorrect.Ventricularprematurebeatsarecommonandtypicallyconsidered
normalwhentheburdenofeventsislow.
41994
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Question289of295
AnelderlymanisseenintheEmergencyDepartmentcomplainingofbreathlessness.Hehasahistoryofasthmaanduses
salbutamolinhalersregularly.Onexamination,hisJVPisraisedwithbilateralpedaloedema.Finecrepitationsand
occasionalwheezingcanbeheardonauscultation.BPis130/80andhisheartrateis98/min.Hisoxygensaturationonair
is99%andhisrespiratoryrateis15.
Giventhelikeliestclinicaldiagnosis,whatwouldbethenextstepinhismanagement?
A Oralfrusemide
B Nebulisedsalbutamol
C Intravenoushydrocortisone
D Nebulisedcorticosteroidandsalbutamol
E IVfrusemideandsalbutamol
Explanation
TheanswerisOralfrusemide
Thisisachallengingquestion.Theclinicalsignsandsymptomssuggestcongestiveheartfailure.Thepresenceof
crepitationsonauscultationsuggestspulmonaryoedema.Thepresenceofraisedvenouspressureandpittingoedema
suggeststhereisrightventricularimpairmentalso.Althoughthereiswheeze,thepresenceofthesetwofactors
stronglysuggestsheartfailureratherthanexacerbationofairwaysdisease.Itiscommontohavesomewheezing,
evenwithpulmonaryoedema.Inthiscase,hischronicuseofinhalerssuggeststhereisunderlyingasthmaorother
airwaysdisease,butthewheezeisonlyoccasionalratherthanwidespread(rulingoutnebulisedsalbutamol,IV
hydrocortisoneandthenebulisedcorticosteroidandsalbutamolchoices).
Regardingthechoiceofdiuretic,weshouldbeguidedbythepatientsclinicalstate.Heismaintaininghisblood
pressure,saturationsandhisrespiratoryrateisnotovertlyraised.Therefore,oralfrusemideshouldbeadequate
therapyforhim.Iftherehadbeendeterioratingsaturationsandraisedrespiratoryrate,IVfrusemidewouldbeamore
appropriatechoice.
Nebulisedsalbutamol(OptionB)isincorrect.Asdescribedthewheezeisonlyoccasionalratherthanwidespread.
Intravenoushydrocortisone(OptionC)isincorrect.Asdescribedthewheezeisonlyoccasionalratherthanwidespread.
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Nebulisedcorticosteroidandsalbutamol(OptionD)isincorrect.Asdescribedthewheezeisonlyoccasionalratherthan
widespread.
IVfrusemideandsalbutamol(OptionE)isincorrect.Asdescribedoraltherapyisamoreappropriateoptionhere.
41897
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Question290of295
A25yearoldcomputerprogrammersuddenlydevelopsdysphasiaandrightsidedweakness.Cardiacexaminationis
normalandheisafebrile.
Whichinvestigationwouldconfirmtheunderlyingcardiologicaldiagnosis?
A ChestXray
B 12leadECG
C 2Dechocardiography
D CarotidDopplerstudy
E Transoesophagealechocardiogramwithbubblestudy
Explanation
TheanswerisTransoesophagealechocardiogramwithbubblestudy
Thepatientinthisscenariohashadasuddenonsetstroke.Thecomputerprogrammercareerimpliesasedentary
lifestylewiththepossibilityofDVT.Theimplicationisthathehashadaparadoxicalembolus.
Patentforamenovale
Ayoung,otherwisehealthypersonwhosuddenlydevelopsastrokeislikelytohaveaparadoxicalembolismdueto
apatentforamenovale(PFO)(orostiumsecundumdefect)
PFOsarerelativelycommonandmaybepresentin2530%ofthegeneralpopulationhowever,thevastmajority
donotcauseaproblem
PFOsgreaterthan4mmandassociatedwithshuntingaremorelikelytobeassociatedwithsystemicemboli
Diagnosis
AchestXraymayshowenlargementoftheheartandpulmonaryarteryaswellaspulmonaryplethora
ECGandechocardiography
IncompleterightbundlebranchblockisseenonECGinsinusrhythm
Echocardiographymaydemonstratethedefectandshowrightventriculardilatationandhypertrophyand
pulmonaryarterydilatation
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However,PFOsmaybemissedona2Dechocardiogram
Theprecisesizeandlocationofthedefectcanbeshownontransoesophagealechocardiography
AtransoesophagealechocardiogramwithDopplercolourflowimagingwouldbetheinvestigationofchoiceinthis
case
ChestXray(OptionA)isincorrect.AChestXrayalonecannotdiagnoseapatentforamenovaleoratrialseptaldefect.
12leadECG(OptionB)isincorrect.A12leadECGalonecannotdiagnoseapatentforamenovaleoratrialseptaldefect.
2Dechocardiography(OptionC)isincorrect.A2DechocardiogramalonecannotexcludeaPFOunlessabubblestudy
andValsalvaareperformedthisisbecauseaPFOisapotentialspace,onlyopenduringValsalvaconditions.Agitated
salineisinjectedintoaveinandthenbubblesareseentofilltherightatrium.ThepatientisaskedtoValsalvaandthiswill
altertheintracardiacpressures,enablingthePFOtoopen,andbubblesareseenenteringtheleftatrium.Sometimes
bubblesareseenintheleftatriumafteradelaythisisashuntingoccurringatthepulmonarycirculation.Bubblestudies
canbeperformedduringtransthoracicandtransoesophagealechocardiograms.
CarotidDopplerstudy(OptionD)isincorrect.CarotidDopplerwouldbehelpfulinolderpatientswherecarotidstenosis
andlocalplaqueruptureisamorelikelyaetiology.
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Question291of295
A42yearoldpainterpresentstotheEmergencyDepartmentwithsymptomsofvertigo,diplopiaandgaitunsteadinessat
theendofabusyafternoonpaintingtheinteriorofaproperty.Onexaminationthereisamarkedlylowerbloodpressurein
theleftarm.
Whatdiagnosisfitsbestwiththisclinicalpicture?
A Anteriorcirculationtransientischaemicattack
B Posteriorcirculationtransientischaemicattack
C Subclavianstealsyndrome
D Unexplainedcardiacarrhythmia
E Vestibularneuronitis
Explanation
TheanswerisSubclavianstealsyndrome
Inthisscenario,thekeypointtopickupisthatthepatientisapainterandthereforewillhavebeenusingonearma
lot.Thiswouldaggravatestealsyndrome,butnottheotherconditions.
Subclavianstealsyndromeresultsfromocclusionorstenosisoftheproximalsubclavianartery,leadingto
decreasedantegradeorretrogradeflowintheipsilateralvertebralartery.
Symptoms
Manypatientsareasymptomatic.
Upperextremitysymptomsincludefatigue,aching,coolnessoftheaffectedarmandsomenumbness.
Neurologicalsymptomsmayincludevertigo,diplopia,decreasedvision,nystagmusandgaitunsteadiness
andoccurinaround25%ofpatients.
Symptomsmaybeprecipitatedbyextremeexerciseontheaffectedside,suchascricketbowling,useofan
underarmcrutchorpaintingawall.
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Pathophysiology
Subclavianstealproducessymptomsbyflowrelatedphenomenaratherthanembolic.
Whenanatheroscleroticlesionintheproximalsubclavianarteryprogressestocausehaemodynamically
significantstenosis,collateralvesselsfromthesubclavianarterygraduallyenlarge.
Theupperextremitybecomesdependentontheselargecollateralbloodvesselsthatoriginatefromthe
subclavianarterydistaltotheobstruction.
Thecollateralvesselsserveaspointsofreentryforbloodflowingretrogradeintothearmfromthehead,
shoulderandneck,therebyprovidingtheextremitywithadequateperfusion.
Whenthearmisexercised,thebloodvesselsdilatetoenhanceperfusiontotheischaemicmuscle,thus
loweringtheresistanceintheoutflowvessels.
Bloodissiphonedfromthehead,neckandshoulderthroughcollateralvesselstosupplythislowresistance
vascularbed,satisfyingincreasedoxygendemandbytheexercisingmusclesoftheupperextremity.
Thisresultsinposteriorcerebralcirculationneurologicalsymptoms
Management
Appropriateimagingstudiesincludenoninvasivearterialflowstudies,Dopplerandarteriography.
Mostpatientsrequirenointervention,althoughsurgicalreconstructionmayberequiredwheresymptomsare
severe.
Anteriorcirculationtransientischaemicattack(TIA)(OptionA)isincorrect.AnteriorTIAwouldpresentwith
dysphasia,visuospatialdisturbanceswithhomonymoushemianopiaandmotorsensorydeficitoftheface,armsandlegs.
NoneispresentandthereforeTIAcanberuledout.
Posteriorcirculationtransientischaemicattack(OptionB)isincorrect.PosteriorcirculationTIAwouldpresentwitha
cranialnervepalsy,bilateralmotor/sensorydefectsandcerebelleardysfunction.Posteriorfeaturesarepresentinpatients
withsubclavianstealwhichbetterexplainsthecasescenario:hehasbeenpainting,whichhasreducedflowtothe
posteriorcirculation.SubclavianstealsyndromeisabetteranswerthanPosteriorcirculationTIA.
Unexplainedcardiacarrhythmia(OptionD)isincorrect.Acardiacarrhythmiaistypicallyassociatedwithpalpitations,
chestpainsandperhapssyncope.Noneispresentandsothisisunlikely.
Vestibularneuronitis(OptionE)isincorrect.Vestibularneuronitisthisisanacutebutsustaineddysfunctionofthe
vestibularsysteminwhichthereisvertigowithnauseaandvomiting.Itdiffersfromlabyrinthitisasauditoryfunctionis
maintained.Althoughhehasvertigo,thechangesinbloodpressureandabnormalityofgaitdonotfit.
42003
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Question292of295
A58yearoldmalepatienthassufferedfromarecentacuteinferiormyocardialinfarction3daysago.Heinitially
recoveredwell,buthasbecomeacutelyunwellwithahypotensiveepisode.Thereisapansystolicmurmur,whichis
accentuatedbyinspiration,alongthelowerleftsternalborder.ASwanGanzcatheterisinsertedandthefollowingnoted:
rightatrialpressureis12(veryhigh)calculatedleftatrialpressureis2(lownormal).
Whichoneofthefollowingisthelikelycause?
A Aorticregurgitation
B Leftheartfailure
C Mitralregurgitation
D Rightheartfailure
E Tricuspidregurgitation
Explanation
TheanswerisTricuspidregurgitation
Therightatrialpressureissignificantlyelevatedwhiletheleftatrialpressureislow.Therefore,theconditionmust
affecttherightsideoftheheartandnottheleft.Tricuspidregurgitationisthecorrectanswerasitalsoexplainsthe
murmurwhichrightsidedheartfailuredoesnotalone.
Tricuspidregurgitation
Tricuspidregurgitationmayoccurinpostmyocardialinfarction,inassociationwith:
corpulmonale
rheumaticheartdisease
infectiveendocarditis
carcinoidsyndrome
Ebsteinanomaly
othercongenitalabnormalitiesoftheatrioventricularvalves.
Signsandsymptoms
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Regurgitationgivesrisetohighrightatrialpressures(asseenhere).
Physicalsignsincludealargejugularvenouscardiovascularwaveandapulsatileliverthatpulsatesinsystole.
Arightventricularimpulsemaybefeltattheleftsternaledgeandthereisablowingpansystolicmurmur.
Othernotes
Severetricuspidregurgitationmayrequirevalverepair,orrarelyreplacement.
Anotherconsiderationwiththistypeofpresentationpostmyocardialinfarctionispulmonaryembolus:ahigh
proportionofthosepatientswhodiepostmyocardialinfarctiondosobecauseofthromboembolicdisease.
Aorticregurgitation(OptionA)isincorrect.Iftherewasaorticregurgitation,thentherewouldbeadiastolicmurmurand
leftsidedpressureswouldbeelevated.
Leftheartfailure(OptionB)isincorrect.Leftheartfailurecannotbetheanswerhereastheatrialpressuresindicatea
conditionaffectingtherightsideoftheheart.
Mitralregurgitation(OptionC)isincorrect.Iftherewasmitralregurgitation,thenleftatrialpressurewouldbehigh.
Rightheartfailure(OptionD)isincorrect.Asdescribed,rightheartfailurealonedoesnotexplainthemurmur.
41996
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Question293of295
A55yearoldmanwhohassustainedanacuteMIsubsequentlypresentwithheartfailure.Aswellasothertreatmentsthe
cardiologisthasrecommendedthatablockerbecommenced.
Accordingtocurrentlyavailableevidence,whichofthefollowingblockerswouldbemostappropriate?
A Celiprolol
B Labetalol
C Bisoprolol
D Propranolol
E Sotalol
Explanation
Betablockers
Betablockersmayproducebenefitinheartfailurebyblockingsympatheticactivity
Bisoprololandcarvedilolreducemortalityinanygradeofstableheartfailure
Treatmentshouldbeinitiatedbythoseexperiencedinthemanagementofheartfailure
Accordingtocurrentlyavailableevidence(seeNICEguidelinesoncardiacfailure,2003),bisoprolol,metoprolol
sustainedreleaseandcarvedilolhaveshownthemostusefuleffects
AtpresentmetoprololisnotlicensedintheUKforthisindicationandsocarvedilolorbisoprololarethepreferred
choices
Propranololisanoncardioselectivebetablockerandthereforehasalessfavourablesideeffectprofilewhen
comparedtobisoprololorcarvedilol
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Question294of295
Youarecalledurgentlytoreviewa54yearoldmanwhohasdevelopedacuteonsetpulmonaryoedemasome36hafter
hismyocardialinfarction.Onarrivalyounotethathisbloodpressureis95/50mmHgwithapulseof110bpmregular,and
apansystolicmurmurisnoted.Therearecracklesonauscultationofthechestconsistentwithheartfailure.
Whichoneofthefollowingrepresentsthenextinvestigationofchoiceinthisman?
A Referralforangiography
B TroponinI
C TroponinT
D UrgentchestXray
E Urgentechocardiogram
Explanation
TheanswerisUrgentechocardiogram
Toanswerthisquestionyoushouldbeawareofthemechanicalcomplicationsofmyocardialinfarction.Thisincludes
acutemitralregurgitation(MR),acuteventricularseptaldefect(VSD)andventricularrupture.Ineachcase,they
presentwithacutedeteriorationofthepatientbothacuteMRandVSDwillhaveanewmurmur,whereasthosewith
rupturewillhavemuffledheartsoundsbeforetamponaderapidlyoccurs.Thesearenowfortunatelylesscommonin
theeraofprimaryangioplasty,butcanstilloccurinpatientswhohavefullthicknessMI.Inallthesecases,urgent
bedsideechocardiographyisrequiredtomakethediagnosis.Alltheothertestsarereasonableandmaybeperformed
however,onlyechocardiographywillgivetherightdiagnosisandhenceisthebestanswer.
Acutemitralregurgitation
Thetimingofthismansdeteriorationcoupledwithamurmurofmitralregurgitationandacutepulmonary
oedemasuggesttheonsetofpapillarymuscledysfunction,orevenrupture
Echocardiogramistheinvestigationofchoicetodemonstratethemitralregurgitation
Alltheothertestsarereasonablebutwouldnotleadtothecorrectdiagnosisforthepatient
ManagementinvolvestheuseofvasodilatorssuchasIVGTN,sodiumnitroprussideandtheuseof
angiotensinconvertingenzyme(ACE)inhibition,iftolerated(unlikelyinthiscaseduetohypotension)
Inotropicsupportwithdrugssuchasdopamineordobutaminemayalsoberequired
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Patientsmayrequirehaemodynamicsupportwithintraaorticballoonpumpswhichsimultaneously
improvecardiacoutputwhilealsoimprovingcoronaryperfusionpressures
Thecaseshouldbediscussedurgentlywithcardiothoracicsurgicalcolleaguestoassesssuitabilityfor
surgicalrepair,althoughthisshouldbepostponeduntilafterhaemodynamicstabilisationifpossible,owing
tothehighrisksofperiinfarctsurgicalintervention.Longdelaysshouldbeavoided,astheriskofdeathis
notmitigateduntilthemitralvalveisrepaired
Referralforangiography(OptionA)isincorrect.Asdescribedthiswouldnotleadtothecorrectdiagnosis.
TroponinI(OptionB)isincorrect.Asdescribedthiswouldnotleadtothecorrectdiagnosis.
TroponinT(OptionC)isincorrect.Asdescribedthiswouldnotleadtothecorrectdiagnosis.
UrgentchestXray(OptionD)isincorrect.Asdescribedthiswouldnotleadtothecorrectdiagnosis.
42018
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Question295of295
A58yearoldmanwithahistoryofhypertension,managedwithramipril10mgdaily,and40packyearsofcigarette
smokingpresentstotheEmergencyDepartmentafteracollapseatwork.Neurologicalexaminationrevealsaleftsided
hemiplegia.Clinicalresultsaregiveninthetablebelow:
Hb 13.8g/dl
WCC 5.4109/l
PLT 192109/l
Na+ 139mmol/l
K+ 4.9mmol/l
Creatinine 149mol/l
CThead nointracerebralhaemorrhageidentified
WhatisthetimelimitaftertheonsetofsymptomsuptowhichIVthrombolysisshouldbeadministered?
A 1h
B 3h
C 4.5h
D 6h
E 12h
Explanation
Thrombolysisguidelines
Although3hwastheinitialtimelimitrecommendedin2004guidelinesfromtheRCP,thenewerguidelineshave
proposedalimitof4.5h
Thistakesintoaccountallcurrentlyavailabledataontheriskbenefitratiooftreatmentwithinthistimeframe
Despiteanincreaseinhaemorrhagictransformationoftheirstroke,thegroupreceivingthrombolysisintheNINDs
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studyhadalowerrateofdeathorseveredisability
BoththeSIGNandRCPguidelinesrecommendthatthrombolysisforstrokeshouldonlybeundertakenina
specialiststrokethrombolysisunit
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