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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

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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.
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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.
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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%

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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.
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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.
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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

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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.
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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

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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.
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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.
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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.

Streptococci Viridansgroup 3040%

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Enterococci 1015%

Other 2025%

Staphylococci Staphylococcusaureus 927%

Coagulasenegative 13%

Gramnegativebacilli Haemophilysspp. 38%

Anaerobes Rickettsia/fungi Lessthan2%

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.
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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.
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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.
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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.
42035

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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

20919

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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

18702

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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.

CHA2DS2VAScscore Annualstrokerisk(%/year) Suggestedmedication

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

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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

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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.
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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
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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

CHA2DS2VAScscore Annualstrokerisk(%/year) Suggestedmedication

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.
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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

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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.
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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

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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.
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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.
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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%.
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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.
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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

20921

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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.
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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.
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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.
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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.
41910

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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

20941

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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

20913

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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.
41979

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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

3094

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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.

Streptococci Viridansgroup 3040%

Enterococci 1015%

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Other 2025%

Staphylococci Staphylococcusaureus 927%

Coagulasenegative 13%

Gramnegativebacilli Haemophilusspp. 38%

Anaerobes Rickettsia/fungi lessthan2%

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.
37794

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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.
37286

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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

21334

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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

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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

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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.
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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

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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

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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.
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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

2858

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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)
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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.
41971

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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

Marker Initialrise Peaklevels Backtonormal

Myoglobin 14h 67h 24h

TroponinI 312h 24h 510d

TroponinT 312h 12h2d 514d

CKMB 312h 24h 4872h

Lactatedehydrogenase 10h 2448h 1014d

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.
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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.
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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.
41941

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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.
41935

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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.
41940

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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.
41957

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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.
41950

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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.
42001

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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.
41939

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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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