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Question 1
Incorrect
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A 25 yr. old previously well male presented with chest discomfort and difficulty in breathing while running to the bus. Symptoms disappeared after resting. But the symptoms reappeared whilst he was climbing the stairs. On examination he was not dyspnoeic at rest. BP was 110/70 mmHg and pulse rate was 72 bpm. His heart sounds were normal. There was an additional clicking noise in the fourth left intercostal space which is heard with each heart beat. Which of the following is the most probable cause for his presentation?
Your Answer: Unstable angina
Correct Answer: Spontaneous pneumothorax
Explanation:The given history is more compatible with spontaneous pneumothorax. Left-sided pneumothoraxes may be associated with a clicking noise, which is heard with each heart-beat and can sometimes be heard by the patient.
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This question is part of the following fields:
- Cardiology
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Question 2
Correct
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A 60 yr. old patient with hypertension attended his regular clinic. His compliance was poor. His blood pressure was 180/100 mmHg. His pulse rate was 85 bpm which was irregularly irregular. On examination there was bibasal crepitation. No murmurs were heard. What is the most likely cause for these findings?
Your Answer: Left ventricular hypertrophy
Explanation:Left ventricular hypertrophy due to long standing hypertension is the most probable cause. The irregularly irregular pulse was suggestive of atrial fibrillation, which is due to diastolic dysfunction. Poor ventricular filling causes pulmonary congestion which manifests as bibasal crepitations.
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This question is part of the following fields:
- Cardiology
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Question 3
Correct
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A 30 yr. old male patient presented with palpitations that occur randomly at rest. There have however been episodes of fast palpitations and dizziness on exertion. On examination there was a systolic murmur at the apex as well as a prominent apex beat and the chest was clear. Which of the following is LEAST likely to suggest a diagnosis of hypertrophic cardiomyopathy?
Your Answer: A history of hypertension for 10 years
Explanation:Hypertrophic cardiomyopathy is an autosomal dominant condition. Patients present with sudden cardiac death, dyspnoea, syncope and presyncope, angina, palpitations, orthopnoea and paroxysmal nocturnal dyspnoea, Congestive heart failure and dizziness. Physical findings include double or triple apical impulse, prominent a wave in the JVP, an ejection systolic crescendo-decrescendo murmur and a holosystolic murmur at the apex and axilla of mitral regurgitation.
ECG shows ST-T wave abnormalities and LVH, axis deviation (right or left), conduction abnormalities (P-R prolongation, bundle-branch block), sinus bradycardia with ectopic atrial rhythm, atrial enlargement, abnormal and prominent Q wave in the anterior precordial and lateral limb leads.
2D echocardiography shows abnormal systolic anterior leaflet motion of the mitral valve, LVH, left atrial enlargement, small ventricular chamber size, septal hypertrophy with septal-to-free wall ratio greater than 1.4:1, mitral valve prolapse and mitral regurgitation, decreased midaortic flow, partial systolic closure of the aortic valve in midsystole -
This question is part of the following fields:
- Cardiology
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Question 4
Correct
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A 60 yr. old man presented with difficulty in breathing. On examination he was severely dyspnoeic and tachycardic. What is the clinical sign that would favour the diagnosis of cardiac tamponade over constrictive pericarditis?
Your Answer: Pulsus paradoxus
Explanation:Pulsus paradoxus is defined as the exaggerated fall in systolic blood pressure during inspiration by greater than 10 mmHg. Cardiac tamponade is the classic cause of pulsus paradoxus. Kussmaul’s sign (a rise in the jugular venous pressure on inspiration) is mostly seen in constrictive pericarditis. Hypotension, muffled heart sounds and raised JVP can be seen in both conditions.
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This question is part of the following fields:
- Cardiology
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Question 5
Correct
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A 60 yr. old female presented after an acute overdose of amiodarone. Her blood pressure was 110/70 mmHg and pulse rate was 35 bpm. She was given 500mcg of atropine but there was no response. Which of the following is the most appropriate next step?
Your Answer: Isoprenaline
Explanation:Permanent pacing is not indicated as the bradycardia is reversible. Temporary pacing is the definite treatment. Isoprenaline can be used until temporary pacing is available.
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This question is part of the following fields:
- Cardiology
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Question 6
Incorrect
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Which of the following describes the reason for the decline of the use of betablockers as antihypertensives in last few years?
Your Answer: Less likely to prevent myocardial infarctions + potential impairment of glucose tolerance
Correct Answer: Less likely to prevent stroke + potential impairment of glucose tolerance
Explanation:According to the latest research, beta blockers are associated with higher incidence of fatal and non-fatal strokes, all cardiovascular events, and cardiovascular mortality. New-onset diabetes also associates with beta blockers.
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This question is part of the following fields:
- Cardiology
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Question 7
Correct
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A 24 yr. old male with a history of a cardiac murmur which was not properly followed up, presented with right sided hemiparesis. His blood pressure was 120/70 mmHg. His ECG revealed right bundle branch block with right axis deviation. Which of the following is the most likely cause for this presentation?
Your Answer: Ostium secundum atrial septal defect
Explanation:Ostium secundum atrial septal defects are known to cause stroke due to the passage of emboli from the right sided circulation to the left sided circulation. ECG shows tall, peaked P waves (usually best seen in leads II and V2) and prolongation of the PR interval, rSR pattern in leads V3 R and V1 as well as right axis deviation.
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This question is part of the following fields:
- Cardiology
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Question 8
Correct
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A 28 yr. old male was admitted with palpitations and chest discomfort for the past 1 hour. On examination his pulse rate was 200 bpm and blood pressure was 80/50 mmHg. His ECG revealed narrow complex tachycardia with a heart rate of 200 bpm. Which of the following is the most appropriate management of this patient?
Your Answer: Synchronised DC synchronised cardioversion
Explanation:Narrow complex tachycardia with hypotension is a medical emergency. Immediate synchronized cardioversion is the ideal management.
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This question is part of the following fields:
- Cardiology
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Question 9
Incorrect
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A 34 yr. old male presented with exertional dyspnoea and chest pain for the past 2 weeks. On examination there was a mid-systolic murmur which is best heard at the apex and double apical impulse. His ECG showed left ventricular hypertrophy (LVH). What is the risk factor which would be most indicative of the potential for sudden death in this patient?
Your Answer: Asymmetrical septal hypertrophy
Correct Answer: Degree of left ventricular hypertrophy
Explanation:The history is suggestive of hypertrophic obstructive cardiac myopathy. The degree of left ventricular hypertrophy is strongly associated with sudden cardiac death.
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This question is part of the following fields:
- Cardiology
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Question 10
Correct
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A 68 yr. old male with history of poorly controlled hypertension was admitted with shortness of breath on exertion, orthopnoea for three months. He was diagnosed with congestive cardiac failure and was started on digoxin 62.5 μg daily, furosemide 80mg daily and amiloride 10mg daily. On admission his lab results showed that his serum urea was 6 mmol/L and serum creatinine was 115 μmol/L. One month later he came for a follow up consultation. On examination he had bilateral ankle oedema. His blood pressure was 138/90 mmHg and pulse rate was 92 bpm. His JVP was not elevated. His apex beat was displaced laterally and he had a few bibasal crepitations on auscultation. There were no cardiac murmurs. His investigation results revealed the following: Serum sodium 143 mmol/L (137-144), Serum potassium 3.5 mmol/L (3.5-4.9), Serum urea 8 mmol/L (2.5-7.5), Serum creatinine 140 μmol/L (60-110), Serum digoxin 0.7 ng/mL (1.0-2.0). CXR showed cardiomegaly and a calcified aorta. ECG showed left ventricular hypertrophy. Which of the following is the most appropriate next step in the management of this patient?
Your Answer: Add an ACE inhibitor to the current regimen
Explanation:From the given history the patient has NYHA grade III heart failure. He can be safely started on an ACE inhibitor as his serum potassium was towards the lower limit. As there an impairment of renal function, his urea, creatinine and serum electrolytes should be closely monitored after commencing an ACE inhibitor. Adding atenolol will not have any clinical benefit. Increasing the digoxin dose is not needed as the patient is in sinus rhythm. Increasing furosemide will only have symptomatic relief.
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This question is part of the following fields:
- Cardiology
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Question 11
Incorrect
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Which of the following is not associated with right axis deviation?
Your Answer: Left posterior hemiblock
Correct Answer: Wolf-Parkinson-White syndrome with right-sided accessory pathway
Explanation:Causes for right axis deviation:
-Right ventricular hypertrophy and Left posterior fascicular block
-Lateral myocardial infarction.
-Acute or chronic lung diseases: Pulmonary embolism, pulmonary hypertension, chronic obstructive pulmonary disease (COPD), cor pulmonale.
-Congenital heart disease (e.g., dextrocardia, secundum atrial septal defect).
-Wolff-Parkinson-White syndrome.
-Ventricular ectopic rhythms (e.g., ventricular tachycardia). -
This question is part of the following fields:
- Cardiology
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Question 12
Correct
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Which of the following is not an indication for an implantable cardiac defibrillator?
Your Answer: Wolff-Parkinson White syndrome
Explanation:Class I indications (i.e., the benefit greatly outweighs the risk, and the treatment should be administered): -Structural heart disease, sustained VT
-Syncope of undetermined origin, inducible VT or VF at electrophysiologic study (EPS)
-Left ventricular ejection fraction (LVEF) ≤35% due to prior MI, at least 40 days post-MI, NYHA class II or III
-LVEF ≤35%, NYHA class II or III
-LVEF ≤30% due to prior MI, at least 40 days post-MI
-LVEF ≤40% due to prior MI, inducible VT or VF at EPSClass IIa indications (i.e., the benefit outweighs the risk and it is reasonable to administer the treatment):
-Unexplained syncope, significant LV dysfunction, nonischaemic cardiomyopathy
-Sustained VT, normal or near-normal ventricular function
-Hypertrophic cardiomyopathy with 1 or more major risk factors
-Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) with 1 or more risk factors for sudden cardiac death (SCD)
-Long QT syndrome, syncope or VT while receiving beta-blockers
-Nonhospitalized patients awaiting heart transplant
-Brugada syndrome, syncope or VT
-Catecholaminergic polymorphic VT, syncope or VT while receiving beta-blockers
-Cardiac sarcoidosis, giant cell myocarditis, or Chagas disease -
This question is part of the following fields:
- Cardiology
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Question 13
Correct
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A 65 yr. old heavy smoker presented with acute central chest pain for 2 hours. Which of the following ECG findings is an indication for thrombolysis in this patient?
Your Answer: 1 mm ST elevation in 2 limb leads
Explanation:Thrombolytic therapy is indicated in patients with evidence of ST-segment elevation MI (STEMI) or presumably new left bundle-branch block (LBBB) presenting within 12 hours of the onset of symptoms if there are no contraindications to fibrinolysis. STEMI is defined as new ST elevation at the J point in at least two contiguous leads of 2 mm (0.2 mV) or more in men or 1.5 mm (0.15 mV) in women in leads V2-V3 and/or 1 mm (0.1 mV) or more in other contiguous limb leads.
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This question is part of the following fields:
- Cardiology
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Question 14
Correct
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A 72 yr. old female patient with a history of atrial fibrillation was admitted with recurrent episodes of syncopal attacks. Her ECG showed torsade de pointes. What is the drug which does not cause the above presentation?
Your Answer: Omeprazole
Explanation:Drugs causing torsades de pointes are Amiodarone, Chlorpromazine, Clarithromycin, Disopyramide, Dofetilide, Erythromycin, Haloperidol, Methadone, Procainamide, Quinidine, Sotalol, Levofloxacin, Moxifloxacin, Nilotinib, Ondansetron, Ranolazine, Sunitinib, Ziprasidone, Amitriptyline, Ciprofloxacin, Imipramine, Chlorthalidone, Dasatinib, Hydrochlorothiazide, Furosemide.
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This question is part of the following fields:
- Cardiology
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Question 15
Correct
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A 60 yr. old man with atrial fibrillation (AF) who is on warfarin, is awaiting tooth extraction. His latest INR 2 weeks ago was 2.7 and his target INR is 2.0-3.0. Which of the following is the most appropriate management?
Your Answer: Check INR 72 hours before procedure, proceed if INR < 3.5
Explanation:The latest research recommends that simple tooth extraction in patients on warfarin treatment can be performed safely without high risk of bleeding, providing that the INR is equal to or less than 3.5 on the day of extraction. A close follow-up and monitoring of patients taking warfarin is mandatory after dental extraction.
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This question is part of the following fields:
- Cardiology
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Question 16
Correct
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A 25 yr. old previously well female, in her 10th week of pregnancy presented with a left sided painful calf swelling. An ultrasound scan revealed deep venous thrombosis (DVT) of her left leg. Which of the following is the most appropriate management of this patient?
Your Answer: Initiate and then continue treatment with heparin until delivery
Explanation:Warfarin is contraindicated during pregnancy due to its teratogenic effects. She should be given heparin throughout her pregnancy. It can be converted to warfarin if necessary after the delivery.
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This question is part of the following fields:
- Cardiology
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Question 17
Correct
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A 60 yr. old male smoker and a known hypertensive presented with central chest pain radiating to the back. On examination he was tachycardic and hypotensive. His ECG showed inferior ST elevation and his transoesophageal echocardiogram showed a double lumen in the ascending aorta. Which of the following is the most probable diagnosis?
Your Answer: Dissecting aortic aneurysm
Explanation:The classic history in this high risk patient is suggestive of a dissecting aortic aneurysm. His transoesophageal echocardiogram confirms the diagnosis. ST elevation in ECG is probably due to the extension of the dissection of the aorta which results in compromised coronary blood supply.
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This question is part of the following fields:
- Cardiology
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Question 18
Correct
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A 70 yr. old male patient presented with chronic congestive heart failure. Which of the following is the most important factor to consider when prescribing drugs for this patient?
Your Answer: Administration of a B-blocker reduces the time spent in hospital
Explanation:It is proven that spironolactone has survival benefits and loop diuretics only give symptomatic relief. Beta blockers are however, known to improve exercise tolerance, left ventricular function and reduce symptoms. They also reduce the mortality associated with heart failure. So administration of beta blockers will reduce the time spent in hospital by improving symptoms.
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This question is part of the following fields:
- Cardiology
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Question 19
Correct
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A 65 yr. male patient was started on warfarin for chronic atrial fibrillation (AF). Which of the following clotting factors is not affected by warfarin?
Your Answer: Factor XII
Explanation:Carboxylation of factor II, VII, IX, X and protein C is affected by warfarin. Factor XII is not affected.
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This question is part of the following fields:
- Cardiology
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Question 20
Correct
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Which of the following is not associated with atrial myxoma?
Your Answer: J wave on ECG
Explanation:J waves in an ECG is associated with hypothermia, hypercalcemia, the Brugada syndrome, and idiopathic ventricular fibrillation. The other responses are all associated with atrial myxoma
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This question is part of the following fields:
- Cardiology
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Question 21
Correct
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A 65 yr. old male presented with acute ST elevation myocardial infarction and thrombolysis was planned. Which of the following is an absolute contraindication for thrombolysis?
Your Answer: Intracerebral Haemorrhage
Explanation:Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial haemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months -
This question is part of the following fields:
- Cardiology
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Question 22
Correct
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A 28 yr. old primigravida in her 24th week of pregnancy presented with a history of palpitations, which are fast and regular. She doesn't complain of any episodes of collapse. On examination she was well, pulse rate was 102 bpm, which was regular and her blood pressure was 110/70 mmHg. Her JVP was not elevated. Heart sounds were normal. ECH showed sinus tachycardia. Which of the following can be expected because of the physiological changes which occur in the boy during pregnancy?
Your Answer: Tachycardia
Explanation:The cardiovascular alterations which occur during pregnancy are for the optimal growth and development of the foetus and help to protect the mother from the risks of delivery, such as haemorrhage. The changes are characterized by an increased vascular volume, cardiac output, and heart rate, with a marked fall in vascular resistance and reduction in blood pressure.
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This question is part of the following fields:
- Cardiology
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Question 23
Incorrect
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A 80 yr. old male patient with ischaemic heart disease, hypertension and dyslipidaemia presented with productive cough, fever with chills and loss of appetite for 4 days. On examination he was unwell and febrile with a temperature of 38.3. His blood pressure was 130/80mmHg and pulse rate was 140 bpm. Respiratory rate was 18 breaths per minute. On auscultation there were crepitations over the left lower zone of his chest. His abdomen was soft and non-tender. ECG showed an irregular narrow complex tachycardia. Which of the following is the most appropriate acute management to treat his tachycardia?
Your Answer: Bisoprolol
Correct Answer: Antibiotics
Explanation:The most likely diagnosis is acute atrial fibrillation (AF) precipitated by acute pneumonia. History of fever, cough and the auscultation findings support it. So the most appropriate management is treating the pneumonia with antibiotics. Treating the underlying cause will reduce the heart rate. Other responses are helpful in the management of chronic AF.
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This question is part of the following fields:
- Cardiology
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Question 24
Correct
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A 30 yr. old male was brought in with a history of a stab injury to left chest. He was complaining of chest pain. On examination he was tachycardic, hypotensive and had an elevated JVP, pulsus paradoxus and muffled heart sounds. Respiratory examination was unremarkable. Which of the following is most probable diagnosis?
Your Answer: Cardiac tamponade
Explanation:Becks triad (hypotension, elevated systemic venous pressure, often with jugular venous distention and muffled heart sounds) is a characteristic collection of clinical findings found in cardiac tamponade. Pulsus paradoxus is also associated with it. The history and clinical findings in this scenario are compatible with the diagnosis of cardica tamponade. The normal respiratory examination excludes tension pneumothorax.
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This question is part of the following fields:
- Cardiology
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Question 25
Correct
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A 28 yr. old primigravida in her 24th week of pregnancy came for the routine follow up. She was asymptomatic at the time of examination. Her blood pressure was 152/92 mmHg and pulse rate was 90 bpm. Her blood pressure at the booking visit had been 132/80 mmHg. Her other examination findings were normal. Which of the following is the best method to use to treat her?
Your Answer: Labetalol
Explanation:Methyldopa is the drug of first choice for the control of mild to moderate hypertension in pregnancy. Labetalol is also considered as a first line drug for hypertension in pregnancy. Calcium channel blockers and hydralazine are considered as second line drugs. Beta-blockers (except labetalol), angiotensin receptor blockers, angiotensin-converting enzyme inhibitors and thiazides are not recommended.
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This question is part of the following fields:
- Cardiology
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Question 26
Incorrect
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A 54 yr. old patient presented with a dry cough after starting treatment for hypertension. He was prescribed ramipril 2.5mg and the dry cough started after that, which disturbed his sleep. His blood pressure was normal. Which of the following is the most appropriate management?
Your Answer: Stop the ramipril and prescribe a different ACE-inhibitor
Correct Answer: Stop the ramipril and prescribe candesartan
Explanation:ACE inhibitors are known to cause a dry cough and they should be stopped, to settle the cough. The next drug of choice is an angiotensin receptor blocker such as candesartan.
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This question is part of the following fields:
- Cardiology
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Question 27
Correct
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A 30 yr. old male with Down's Syndrome was found to have a systolic murmur during routine clinical examination. Which of the following is the most common cardiac defect associated with Down's Syndrome which will explain this finding?
Your Answer: Endocardial cushion defect
Explanation:Atrioventricular septal defect (AVSD) also known as endocardial cushion defect is the most common cardiac abnormality in Down’s Syndrome.
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This question is part of the following fields:
- Cardiology
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Question 28
Correct
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A 25 yr. old male presented with an episode of syncope. His examination findings were normal. He gave a history of sudden cardiac death of a close relative. His ECG showed incomplete right bundle-branch block and ST-segment elevations in the anterior precordial leads. What is the most probable diagnosis?
Your Answer: Brugada syndrome
Explanation:Brugada syndrome is an autosomal dominant disorder characterized by sudden cardiac death. The positive family history and characteristic ECG findings are in favour of Brugada syndrome. Usually the physical findings are normal.
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This question is part of the following fields:
- Cardiology
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Question 29
Correct
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A 85 yr. old male with a history of hypertension presented with a couple of pre-syncopal episodes. He describes these episodes as him having felt as if he was going to faint and he has had to sit down. There were no precipitating factors, associated chest pain or palpitations. He doesn't have chest pain, shortness of breath on exertion, orthopnoea or paroxysmal nocturnal dyspnoea. On examination he looked well. Blood pressure was 140/80 mmHg and pulse rate was 78 bpm which was irregular. His lungs were clear and heart sounds were normal. ECG showed sinus rhythm with occasional ventricular ectopic beats. Which of the following is an indication for permanent pacemaker implantation?
Your Answer: Second-degree block associated with symptoms
Explanation:Indications for permanent pacemaker implantation
-Sinus node dysfunction
-Acquired Atrioventricular(AV) block (Complete third-degree AV block with or without symptoms, Symptomatic second degree AV block, Mobitz type I and II, Exercise-induced second or third degree AV block in the absence of myocardial infarction, Mobitz II with widened QRS complex)
-Chronic bifascicular block
-After acute phase of myocardial infarction
-Neurocardiogenic syncope and hypersensitive carotid sinus syndrome
-Post cardiac transplantation
-Hypertrophic cardiomyopathy
-Pacing to detect and terminate tachycardia
-Cardiac resynchronization therapy in patients with severe systolic heart failure
-Patients with congenital heart disease -
This question is part of the following fields:
- Cardiology
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Question 30
Incorrect
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A 72 yr. old male with a history of type II diabetes mellitus and hypertension for 15 years, presented with gradual onset difficulty in breathing on exertion and bilateral ankle swelling for the past 3 months. On examination he had mild ankle oedema. His JVP was not elevated. His heart sounds were normal but he had bibasal crepitations on auscultation. Which of the following clinical signs has the greatest sensitivity in detecting heart failure in this patient?
Your Answer: Pulmonary crackles
Correct Answer: Third heart sound
Explanation:The presence of a third heart sound is the most sensitive indicator of heart failure. All of the other signs can be found in heart failure with varying degrees.
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This question is part of the following fields:
- Cardiology
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Question 31
Correct
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A 60 yr. old man presented with severe central chest pain for the last 2 hours. He was on insulin for diabetes mellitus and he was dependent on haemodialysis because of end stage renal failure. He had undergone haemodialysis 48 hours prior to this presentation. His ECG showed an acute inferior myocardial infarction. Despite thrombolysis and other appropriate treatment, he continued to have chest pain after 6 hours from the initial presentation. His blood pressure was 88/54 mmHg and he had bibasal crepitations. His investigation results are given below. Serum sodium 140 mmol/l (137-144), Serum potassium 6.6 mmol/l (3.5-4.9), Serum urea 50 mmol/l (2.5-7.5), Serum creatinine 940 μmol/l (60-110), Haemoglobin 10.2g/dl (13.0-18.0), Troponin T >24 g/l (<0.04), Left ventricular ejection fraction was 20%. What is the most appropriate management for this patient?
Your Answer: Coronary angiography and rescue PCI
Explanation:According to the history the patient has cardiogenic shock and pulmonary oedema. On-going ischaemia is indicated by persisting symptoms. So the most appropriate management is coronary angiography and rescue PCI. There are no indications for blood transfusion at this moment and it will aggravate the pulmonary oedema. Haemodialysis, beta blockers and furosemide cannot be given due to low blood pressure.
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This question is part of the following fields:
- Cardiology
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Question 32
Correct
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A 32 yr. old primigravida in her 37th week of pregnancy was admitted for the management of pre-eclampsia. Her blood pressure was 180/110 mmHg and urine protein was +++. Magnesium sulphate was started. Which of the following are important parameters that should be monitored during the administration of magnesium sulphate?
Your Answer: Reflexes + respiratory rate
Explanation:The clinical effect and toxicity of MgSO4 can be linked to its concentration in plasma. A concentration of 1.8 to 3.0 mmol/L has been suggested for treatment of eclamptic convulsions. Maternal toxicity is rare when MgSO4 is carefully administered and monitored. The first warning of impending toxicity in the mother is loss of the patellar reflex at plasma concentrations between 3.5 and 5 mmol/L. Respiratory paralysis occurs at 5 to 6.5 mmol/L. Cardiac conduction is altered at greater than 7.5 mmol/L, and cardiac arrest can be expected when concentrations of magnesium exceed 12.5 mmol/L. Careful attention to the monitoring guidelines can prevent toxicity. Deep tendon reflexes, respiratory rate, urine output and serum concentrations are the most commonly monitored parameters.
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This question is part of the following fields:
- Cardiology
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Question 33
Correct
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A 13 yr. old boy presented with difficulty in breathing on exertion. According to his mother who was also present, his exercise tolerance has been gradually worsening for the past weeks. It has reached the point where he is unable to participate in his weekly soccer match. Cardiac catherization was performed and the results are given below: (Anatomical site vs Oxygen saturation (%)vs Pressure (mmHg)) Superior vena cava: 73 ,–. Right atrium: 71, 6. Right ventricle: 72, –. Pulmonary artery: 86, 53/13. PCWP: –, 15. Left ventricle: 97, 111/10. Aorta: 96, 128/61. Which of the following is the diagnosis?
Your Answer: Patent ductus arteriosus
Explanation:The oxygen saturation in the pulmonary artery is higher than that of the right ventricle. The pressure of the pulmonary artery and of the PCWP are also high. So patent ductus arteriosus is highly suggestive.
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This question is part of the following fields:
- Cardiology
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Question 34
Correct
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A 60 yr. old male presented with ventricular tachycardia which was successfully cardioverted. To check whether he had prolonged QT interval, which of the following is the most appropriate method to measure the QT interval in ECG?
Your Answer: Time between the start of the Q wave and the end of the T wave
Explanation:The QT interval is the time from the start of the Q wave to the end of the T wave. It represents the time taken for ventricular depolarisation and repolarisation. The QT interval should be measured in either lead II or V5-6.
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This question is part of the following fields:
- Cardiology
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Question 35
Incorrect
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A 50 yr. old male presented with acute severe central chest pain and acute ST elevation myocardial infarction was diagnosed. He was treated with streptokinase. 2 days later he was sweating excessively and he was found to be hypotensive. Which of the following cannot be considered as a reason for this presentation?
Your Answer: Mitral regurgitation
Correct Answer: Hypotensive effect of streptokinase
Explanation:Hypotensive effect of streptokinase occurs during the streptokinase infusion which is usually transient. Acute mitral regurgitation due to rupture of papillary muscles, ventricular septal defects and reinfarctions (left or right) are known to cause hypotension after 24 hrs. Pulmonary embolism is less likely but cannot be excluded.
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This question is part of the following fields:
- Cardiology
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Question 36
Correct
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A 25 yr. old male presented with acute severe central chest pain which radiated backwards between his scapulae. He didn't have difficulty in breathing and the pain wasn't exacerbated by deep inspiration or a change in position. His father had died due to a heart disease when he was small. He also has a cardiac murmur which was never properly investigated. On examination he was tachycardic with a BP of 165/60 mmHg. There was a diastolic murmur at lower left sternal border which is best heard with the patient sitting forward. Which of the following is the most probable cause for his chest pain?
Your Answer: Aortic dissection
Explanation:The most probable diagnosis is Marfan’s syndrome because of a family history of cardiac death and heart murmurs. A characteristic feature is pain which radiates to the back. A wide pulse pressure and a diastolic heart murmur is suggestive of aortic dissection.
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This question is part of the following fields:
- Cardiology
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Question 37
Correct
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A 62 yr. old male presented with worsening breathlessness and fatiguability. On examination there was bilateral ankle swelling and pulsatile liver. Auscultation revealed a pansystolic murmur best heard at the lower left sternal border. Which of the following is the most probable diagnosis?
Your Answer: Tricuspid regurgitation
Explanation:All the clinical features are suggestive of tricuspid regurgitation. The pansystolic murmur of mitral regurgitation is best heard at the apex.
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This question is part of the following fields:
- Cardiology
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Question 38
Incorrect
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What is correct statement regarding pulsus alternans?
Your Answer: It is diagnosed electrocardiographically
Correct Answer: It is found in association with a third heart sound
Explanation:Pulsus alternans is the alternation of one strong and one weak beat without a change in the cycle length. It occurs most commonly in heart failure due to increased resistance to LV ejection, as occurs in hypertension, aortic stenosis, coronary atherosclerosis, and dilated cardiomyopathy. Pulsus alternans is usually associated with an S3 gallop, which is associated with a poor prognosis. It usually disappears with treatment of the heart failure.
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This question is part of the following fields:
- Cardiology
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Question 39
Incorrect
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A 60 yr. old male patient with hypertension presented with acute onset retrosternal chest pain for 3 hours. On examination his pulse rate was 68 bpm, BP was 100/60 mmHg and JVP was seen 3mm from the sternal notch. Respiratory examination was normal. His ECG showed narrow QRS complexes, ST segment elevation of 2mm in leads II, III and aVF and a complete heart block. What is the most immediate treatment from the following answers?
Your Answer: Temporary transcutaneous pacemaker
Correct Answer: Chewable aspirin 300 mg
Explanation:The diagnosis is inferior ST elevation myocardial infarction. As the right coronary artery supplies the SA and AV nodes and bundle of His, conduction abnormalities are more common with inferior MIs. The most immediate drug management is high dose Aspirin. Definite treatment is urgent cardiac revascularization.
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This question is part of the following fields:
- Cardiology
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Question 40
Correct
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A 65 yr. old previously well man was referred due to an abnormal heart sound which was detected during a medical check up. On examination he looked well. His blood pressure was 120/70 mmHg and pulse rate was 68 bpm which was regular. His jugular venous pressure was not elevated and he didn't have ankle oedema. He had an early diastolic murmur, best heard at the left sternal edge, which was more clear in expiration when the patient leant forward. His lungs were clear. His FBC, Urea and electrolytes, LFTs and lipid profile were normal. His ECG showed sinus rhythm. His chest X-ray was normal. Echocardiography showed mild to moderate aortic regurgitation with normal left ventricular size and normal function. Which of the following is the most appropriate way of managing this patient?
Your Answer: Start him on an angiotensin-converting enzyme (ACE) inhibitor
Explanation:Although this patient’s left ventricular function is normal at the time of examination, there is chance of deterioration of it due to aortic regurgitation. It is found that ACE inhibitors slow the development of left ventricular dysfunction. So this patient should be started on an ACE inhibitor.
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This question is part of the following fields:
- Cardiology
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Question 41
Incorrect
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A 70 yr. old man underwent temporary transvenous pacing. While in the coronary care unit he developed pre-syncope. His pulse rate was 30 bpm. His ECG showed pacing spikes which were not related to QRS complexes. What is the most appropriate action that can be taken?
Your Answer:
Correct Answer: Increase the pacing voltage to a maximum
Explanation:Pacemaker spikes on the ECG indicate that pacemaker is functioning. The most probable cause for this presentation is the change of the position of the tip of the pacing wire. Increasing the voltage will solve the problem. If it works, repositioning of the pacing wire should be done.
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This question is part of the following fields:
- Cardiology
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Question 42
Incorrect
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A 30 yr. old primigravida in her 23rd week of pregnancy presented with palpitations. Her ECG showed supraventricular tachycardia (SVT). 15 minutes after admission the SVT spontaneously reverted to sinus rhythm. She had two episodes of SVT later which were associated with palpitations. Which of the following is the most appropriate treatment for this presentation?
Your Answer:
Correct Answer: Verapamil
Explanation:Both long-acting calcium channel blockers and beta blockers improve symptoms of patients with SVT. Verapamil does not have adverse maternal or fetal side effects which would suggest that the use of verapamil in the treatment of supraventricular arrhythmias in pregnancy is safe and effective. Beta blockers are associated with intrauterine fetal growth restriction.
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This question is part of the following fields:
- Cardiology
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Question 43
Incorrect
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A 60 yr. old previously well male patient was admitted with acute severe central chest pain associated with excessive sweating and nausea for the past 45 minutes. On examination he was found to have xanthelasma. His blood pressure was 170/100 mmHg and pulse rate was 104 bpm. His ECG showed ST elevation more than 2mm in leads II, III and aVF. His troponin T was 120 ng/ml. His FBC and renal functions were normal. He was given aspirin, clopidogrel, morphine and IV 5mg of atenolol. Which of the following is the most appropriate next step?
Your Answer:
Correct Answer: Immediate referral to cardiologist for primary angioplasty
Explanation:The diagnosis is acute inferior ST elevation myocardial infarction so the most appropriate management is primary angioplasty.
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This question is part of the following fields:
- Cardiology
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Question 44
Incorrect
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Which of the following gives the annual incidence of deep venous thrombosis (DVT) in the general population?
Your Answer:
Correct Answer: about 2 per 1000
Explanation:Annual incidence of DVT in the general population is about 1 per 1000 adults. So the most suitable answer is about 2 per 1000.
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This question is part of the following fields:
- Cardiology
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Question 45
Incorrect
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A 42 yr. old male patient who was on enalapril for hypertension presented with generalized body weakness. Investigations revealed hyperkalaemia. Which of the following can be expected in his ECG?
Your Answer:
Correct Answer: Tall, tented T waves
Explanation:In hyperkalaemia the ECG will show tall, tented T waves as well as small P waves and widened QRS complexes.
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This question is part of the following fields:
- Cardiology
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Question 46
Incorrect
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A 28 yr. old male was screened for hypertrophic cardiomyopathy (HOCM). His father has passed away recently at the age of 48 and found to have HOCM during post mortem examination. On examination of this patient his BP was 142/84 mmHg and pulse rate was 68 bpm which was regular. There was a mid systolic murmur and a double apex beat. Echocardiography showed a septal wall thickness of 3.3 cm. What is the factor most closely linked to his 20 year risk of sudden cardiac death?
Your Answer:
Correct Answer: Septal wall thickness of 3.3 cm
Explanation:There are five prognostic factors which indicate poor prognosis in HOCM:
-family history of HOCM-related sudden cardiac death
-unexplained recent syncope
-large left ventricular wall thickness (MLVWT ≥ 30 mm)
-multiple bursts of nsVT on ambulatory electrocardiography
-hypotensive or attenuated blood pressure response to exercise -
This question is part of the following fields:
- Cardiology
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Question 47
Incorrect
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A 75 yr. old male with rheumatoid arthritis underwent a colectomy 2 days ago for colon cancer. He was put on a prophylactic dose of low molecular weight heparin post operatively as well as prednisolone. Now he complains of central chest pain and his ECG revealed an acute ST elevation myocardial infarction. He was given aspirin and oxygen as the initial treatment. Which of the following is the most appropriate management for this patient?
Your Answer:
Correct Answer: IV diamorphine + arrange percutaneous coronary intervention
Explanation:There is a high risk of bleeding due to recent surgery and heparin. So thrombolysis is not an option. The most appropriate management is percutaneous coronary intervention.
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This question is part of the following fields:
- Cardiology
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Question 48
Incorrect
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A 50 yr. old male patient presented with acute chest pain and a non ST elevation myocardial infarction (NSTEMI) was diagnosed. He was threated with aspirin 300mg and 2 puffs of glyceral trin (GTN) spray. According to NICE guidelines, which of the following categories of patients should receive clopidogrel?
Your Answer:
Correct Answer: All patients
Explanation:According to NICE guidelines (2013) all people who have had an acute MI treatment should be offered with ACE inhibitor, dual antiplatelet therapy (aspirin plus a second antiplatelet agent), a beta-blocker and a statin.
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This question is part of the following fields:
- Cardiology
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Question 49
Incorrect
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A 60 yr. old man with previous history of myocardial infarction and hypertension presented with severe retrosternal chest pain for the past 2 hours. During initial management he collapsed and pulseless ventricular tachycardia was detected. The external defibrillator arrived in 3 minutes. From the following answers, what is the most appropriate immediate management of this patient?
Your Answer:
Correct Answer: He should be given a precordial thump
Explanation:A precordial thumb is not routinely recommended because of its very low success rate for cardioversion of a shockable rhythm. It’s only recommended when there is a delay in getting the defibrillator.
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This question is part of the following fields:
- Cardiology
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Question 50
Incorrect
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A 50 yr. old male presented with episodes of collapse during the last month. Each episode persisted for about 2-3 minutes. They were self-limiting and associated with twitching of the limbs. There was no associated tonic-clonic movements, tongue biting, urinary or faecal incontinence. On examination he had reversed splitting of S2 and an ejection systolic murmur at the right sternal border. His electrocardiogram (ECG) showed left ventricular hypertrophy with strain pattern. CXR showed an area of calcification over the cardiac silhouette. Which of the following is the most probable diagnosis of this patient?
Your Answer:
Correct Answer: Aortic stenosis
Explanation:The classic triad of symptoms in patients with aortic stenosis is chest pain, heart failure and syncope. Pulsus parvus et tardus, pulsus alternans, hyperdynamic left ventricle, reversed splitting of the S2, prominent S4 and systolic murmur are some of the common findings of aortic stenosis. A calcified aortic valve is found in almost all adults with hemodynamically significant aortic stenosis.
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This question is part of the following fields:
- Cardiology
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Question 51
Incorrect
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A 52 yr. old female who was a smoker, with a history of asymptomatic atrial septal defect (ASD) presented with difficulty in breathing on exertion and ankle oedema for the past 2 weeks. She has defaulted on her follow up for ASD. On examination she was cyanosed and clubbing was noted. Her pulse rate was 92 and blood pressure was 100/60 mmHg. Echocardiography revealed a dilated right ventricle of the heart. The right ventricular pressure was 90 mmHg. Significant tricuspid and pulmonary regurgitation were also noted. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Eisenmenger’s syndrome
Explanation:According to echocardiography findings pulmonary pressure is closer to systemic blood pressure and it is evidence of pulmonary hypertension. Because of the reversal of shunt due to pulmonary hypertension, cyanosis and clubbing have developed. So the most probable diagnosis is Eisenmenger’s syndrome.
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This question is part of the following fields:
- Cardiology
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Question 52
Incorrect
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A 35 yr. old female with systemic lupus erythematosus (SLE) was brought to Casualty, complaining of chest pain and worsening difficulty in breathing for the past 36 hrs. On examination she was tachypnoeic, her BP was 85/65 mmHg and peripheral oxygen saturation was 98% on air. Her cardiac examination was normal but her jugular venous pressure was elevated. She didn't have ankle oedema. Her ECG showed sinus tachycardia and her CXR showed clear lung fields with a slightly enlarged heart. Which of the following is the most appropriate next step?
Your Answer:
Correct Answer: Urgent transthoracic echocardiogram
Explanation:Acute breathlessness in SLE can be due to a pericardial effusion or a pulmonary embolism. Normal peripheral oxygen saturation and normal ECG, make the diagnosis of pulmonary embolism less likely. To exclude pericardial effusion, an urgent transthoracic echocardiogram is needed.
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This question is part of the following fields:
- Cardiology
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Question 53
Incorrect
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A 30 yr. old male, who is the brother of a patient with hypertrophic cardiomyopathy has come for the screening. Which of the following is the most appropriate method of screening?
Your Answer:
Correct Answer: Echocardiography
Explanation:12-lead electrocardiography and transthoracic echocardiography are recommended as a screening method for family members of patients with HCM.
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This question is part of the following fields:
- Cardiology
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Question 54
Incorrect
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Which of the following statements describe the mechanism of fibrates most accurately?
Your Answer:
Correct Answer: Increased lipoprotein lipase activity via PPAR-alpha
Explanation:The main mechanism of fibrate drugs is activation of gene transcription factors known as PPARs, particularly PPAR-α, which regulate the expression of genes that control lipoprotein metabolism. There are several consequences of PPAR-α activation, which reduce circulating LDL cholesterol and triglycerides and increase HDL cholesterol.
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This question is part of the following fields:
- Cardiology
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Question 55
Incorrect
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Which of the following is suggestive of co-existence of mitral regurgitation and mitral stenosis?
Your Answer:
Correct Answer: Displaced apex beat
Explanation:Apex beat displacement is caused by mitral regurgitation and because it is not found in mitral stenosis, it is suggestive of mixed mitral disease. The other given responses occur in mitral stenosis.
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This question is part of the following fields:
- Cardiology
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Question 56
Incorrect
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Which of the following is the site where B-type natriuretic peptide is mainly secreted?
Your Answer:
Correct Answer: Ventricular myocardium
Explanation:B-type natriuretic peptide (BNP) is secreted mainly from the left ventricle and it is secreted as a response to stretching caused by increased ventricular blood volume.
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This question is part of the following fields:
- Cardiology
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Question 57
Incorrect
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A 65 yr. old male patient admitted with myocardial infarction received thrombolysis, which lead to full resolution of the ST elevations on his ECG. He was on aspirin, clopidogrel, atorvastatin and enalapril. The next day he complained of pain in his legs and there was a diffuse petechial rash over his lower legs, especially in the feet. All his peripheral pulses were palpable. His FBC revealed neutrophilia with eosinophilia. His IgE antibodies were 3 kU/L (<2). What is the most likely reason for this presentation?
Your Answer:
Correct Answer: Cholesterol emboli
Explanation:He has a consequence of atherosclerotic disease (MI). The most probable diagnosis is cutaneous cholesterol emboli as it is more common after anticoagulation or thrombolytics, the skin involvement, eosinophilia and raised IgE. It is more common above 60 yrs. of age.
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This question is part of the following fields:
- Cardiology
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Question 58
Incorrect
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A 70 yr. old female was brought in by the paramedics after she collapsed whilst shopping. She has a tachycardia of 150 bpm and her BP is 100/60 mmHg. Her ECG showed a broad complex tachycardia. Which of the following is more suggestive of a ventricular tachycardia (VT) over a supraventricular tachycardia (SVT) with aberrant conduction?
Your Answer:
Correct Answer: Atrioventricular dissociation
Explanation:To differentiate VT from SVT with aberrant conduction the following electrocardiographic features should be looked for:
Evidence of preceding atrial activity for SVT. Oesophageal leads are helpful if P waves are hidden in the QRS complex.
QRS duration more than 140 ms for VT.
QRS morphology: Features of QRS morphology that favour SVT are RBBB or triphasic patterns like rSR in V1 and qRS in V6. Monophasic pattern like R or qR in V1 and rS or QS in V6 or multiple morphology QRS complexes favour VT.
AV dissociation for VT. -
This question is part of the following fields:
- Cardiology
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Question 59
Incorrect
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A 55 yr. old male with a history of myocardial infarction 4 years ago, was admitted with a history of fever for the past 2 weeks. On investigation, his echocardiography revealed a small vegetation around the mitral valve. His blood culture was positive for Streptococcus viridans. Which of the following is the most appropriate antibiotic therapy?
Your Answer:
Correct Answer: IV benzylpenicillin
Explanation:According to the American Heart Association (AHA) penicillin-susceptible S viridans, S bovis, and other streptococci (MIC of penicillin of ≤0.1 mcg/mL) should be treated with penicillin G or ceftriaxone or penicillin G + a gentamicin combination or vancomycin (if allergy to penicillin).
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This question is part of the following fields:
- Cardiology
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Question 60
Incorrect
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A 42 yr. old man presented with palpitations and shortness of breath on exertion. On examination his lungs were clear and heart sounds were normal. There was a left sided parasternal heave. His electrocardiogram (ECG) revealed atrial fibrillation with right axis deviation. Echocardiography showed dilated right heart chambers. Left and right heart catheterisation study revealed the following: Inferior vena cava Oxygen saturations 63 %, Superior vena cava Oxygen saturations 59 %, Right atrium Oxygen saturations 77 %, Right ventricle Oxygen saturations 78 %, Pulmonary artery Oxygen saturations 82 %, Arterial saturation Oxygen saturations 98 %. What is the most likely diagnosis from the following answers?
Your Answer:
Correct Answer: Atrial septal defect
Explanation:Right ventricular volume overload is indicated by a parasternal heave and right axis deviation. Oxygen saturation in right atrium is higher than oxygen saturation of the inferior and superior vena cavae. So the most probable diagnosis is atrial septal defect.
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This question is part of the following fields:
- Cardiology
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Question 61
Incorrect
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A 60 yr. old male with no past medical history presented to Casualty with acute chest pain. ST elevation myocardial infarction (STEMI) is diagnosed following an ECG on arrival. He was subsequently successfully thrombolysed. Which of the following combinations of drugs is the most suitable combination for him to be taking 4 weeks after his STEMI?
Your Answer:
Correct Answer: ACE inhibitor + beta-blocker + statin + aspirin + clopidogrel
Explanation:According to NICE guidelines (2013) all people who have had an acute MI, treatment should be offered with ACE inhibitor, dual antiplatelet therapy (aspirin plus a second antiplatelet agent), beta-blocker and a statin.
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This question is part of the following fields:
- Cardiology
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Question 62
Incorrect
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A 60 year old male patient with a history of heavy smoking was admitted complaining of acute severe central chest pain for the past one hour. His blood pressure was 150/90 mmHg and pulse rate was 88 bpm. His peripheral oxygen saturation was 93%. ECG showed ST elevation > 2mm in lead II, III and aVF. He was given loading doses of aspirin, clopidogrel and atorvastatin and face mask oxygen was given. Which one of the following investigations should be done and then depending on result, definitive treatment can be initiated?
Your Answer:
Correct Answer: None
Explanation:The history and ECG findings are adequate to begin cardiac revascularization of this patient. There is no need for cardiac markers to confirm the diagnosis. Further delay in starting definite treatment is not recommended.
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This question is part of the following fields:
- Cardiology
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Question 63
Incorrect
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A 50 yr. old smoker with a history of hypertension presented with acute severe chest pain and acute myocardial infarction was diagnosed. Which of the following is a contraindication for thrombolysis?
Your Answer:
Correct Answer: History of likely ischaemic stroke within the past month
Explanation:Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial haemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months -
This question is part of the following fields:
- Cardiology
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Question 64
Incorrect
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A 65 yr. old male with a history of smoking and alcohol was admitted with an ST elevation myocardial infarction. He was obese and lives a sedentary lifestyle. What is the non-pharmacological intervention which will be most helpful to reduce future ischaemic events?
Your Answer:
Correct Answer: Stopping smoking
Explanation:Stopping smoking is the single most effective non-pharmacological intervention which will reduce future ischaemic events. But the rest of the responses are also important interventions with regards to reducing future ischaemic events.
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This question is part of the following fields:
- Cardiology
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Question 65
Incorrect
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A 80 yr. old male was found on the floor. His blood pressure was 100/60 mmHg. His core temperature was 31ºC. His FBC and serum electrolytes were within normal limits. Which of the following would be found in his ECG?
Your Answer:
Correct Answer: Long QT interval
Explanation:Hypothermia is defined as a core body temperature of < 35 °C.
Hypothermia may produce the following ECG changes:
-Bradyarrhythmia
-Osborne Waves (= J waves)
-Prolonged PR, QRS and QT intervals
-Shivering artefact
-Ventricular ectopics
-Cardiac arrest due to VT, VF or asystole -
This question is part of the following fields:
- Cardiology
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Question 66
Incorrect
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A 85 yr. old previously well man was found to have a BP of 155/90 mmHg. His average reading from the monitoring of his ambulatory BP was 147/92 mmHg. His calculated 10 year cardiovascular risk was 15%. Which of the following is the most appropriate management of this patient?
Your Answer:
Correct Answer: Give lifestyle advice and repeat blood pressure in 6 months
Explanation:According to different guidelines for patients above 80 years, the targeted systolic blood pressure varies from 140-150 mmHg. As this patient’s BP is within that range, he can be kept under observation.
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This question is part of the following fields:
- Cardiology
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Question 67
Incorrect
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A 50 yr. old male patient with schizophrenia complained of chest pain and palpitations. His ECG revealed torsades de pointes ventricular tachycardia. He was on thioridazine for schizophrenia. What is the most appropriate management for his presentation?
Your Answer:
Correct Answer: IV magnesium
Explanation:Thioridazine has a quinidine-like action on the heart and is known to cause cardiac arrhythmias including prolonged PR and QT intervals and widening of QRS complexes. Intravenous magnesium sulphate is regarded as the treatment of choice for this arrhythmia.
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This question is part of the following fields:
- Cardiology
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Question 68
Incorrect
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A 45 yr. old male was discharged recently after treatment of bleeding peptic ulcers. 3 days after discharge he was readmitted complaining of acute severe chest pain for the past 1 hour. His ECG showed an acute ST elevation myocardial infarction. His FBC, blood urea, serum electrolytes and serum creatinine were within normal ranges. Faecal occult blood was negative. Which of the following is the most appropriate management for this patient?
Your Answer:
Correct Answer: Primary angioplasty
Explanation:The patient has a recent history of bleeding peptic ulcer disease, which is an absolute contraindication for thrombolysis. So he should be offered primary angioplasty.
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This question is part of the following fields:
- Cardiology
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Question 69
Incorrect
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A 50 yr. old male patient was started on amiodarone. Prior to commencement, his blood urea and electrolytes were checked. What is the reason for doing this investigation before starting amiodarone?
Your Answer:
Correct Answer: To detect hypokalaemia
Explanation:Any antiarrhythmic drugs can potentially cause arrhythmias. Before starting amiodarone, any electrolyte imbalance including hypokalaemia, hypomagnesemia, or hypocalcaemia should be corrected to prevent any arrhythmias.
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This question is part of the following fields:
- Cardiology
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Question 70
Incorrect
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A 42 yr. old previously well woman presented with acute severe central chest pain for the past 2 hours. She has a family history of premature coronary artery disease. Her husband passed away recently due to prostate cancer. On examination her blood pressure was 130/80 mmHg and pulse rate was 80 bpm. Her ECG showed ST segment elevation and her troponin was slightly elevated. Emergency angiogram revealed slight wall irregularities with no luminal obstruction. Cardiovascular MR showed an apical ballooning of the myocardium resembling an octopus pot. Which of the following is the most likely cause for the ST segment elevation?
Your Answer:
Correct Answer: Takotsubo cardiomyopathy
Explanation:Causes for ST segment elevation other than myocardial infarction
Natural variants
-Early repolarization
-Left ventricular hypertrophy and hypertrophic cardiomyopathy
-Left bundle branch block
Artefacts
-Leads mispositioning
-Electrical cardioversion
Cardiovascular diseases
-Pericarditis/ Myocarditis
-Aortic dissection
-Prinzmetal’s angina
-Takotsubo Cardiomyopathy
-Brugada Syndrome and arrhythmogenic right ventricular cardiomyopathy/dysplasia
Pulmonary diseases
-Pulmonary thromboembolism
-Pneumothorax
-Atelectasis and pulmonary metastases
Gastrointestinal diseases
-Acute pancreatitis
-Acute cholecystitis
Other conditions
-Hyperkalaemia
-Drug induced ST segment elevation (e.g. – clozapine)
-Haemorrhagic cerebrovascular diseaseCoronary artery disease and myocardial infarction can be excluded with a negative angiogram and a slightly elevated troponin. Hypertrophic cardiomyopathy can be excluded with cardiovascular MR findings. Left ventricular aneurysm usually occurs following a myocardial infarction, but there is no positive history for that. The characteristic findings on cardiovascular MR confirms the diagnosis of Takotsubo cardiomyopathy.
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This question is part of the following fields:
- Cardiology
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Question 71
Incorrect
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A 54 yr. old heavy smoker presented with acute chest pain for 3 hrs which associated with excessive sweating and vomiting. His past medical history was unremarkable but his father has passed away due to a heart attack at the age of 50. Examination findings were normal and ECG was also normal. He was pain free after 12 hours from admission. What is the most appropriate investigation that cab be done at this moment?
Your Answer:
Correct Answer: Troponin T
Explanation:The positive family history and the smoking make him an ideal candidate for a myocardial infarction. The chest pain is also a suggestive symptom. So troponin is needed to rule out MI.
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This question is part of the following fields:
- Cardiology
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Question 72
Incorrect
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A 65 yr. old male patient presented with acute severe central chest pain for one hour. His ECG confirmed the diagnosis of acute ST elevation myocardial infarction and he was treated with thrombolysis. Two days later he developed sudden onset breathlessness and became unwell. On examination he had bibasal crepitation and a systolic murmur at the apex which radiated to the axilla. Which of the following is the most likely cause for this presentation?
Your Answer:
Correct Answer: Ruptured papillary muscle
Explanation:The most likely cause for acute breathlessness is due to papillary muscle rupture which causes mitral regurgitation.
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This question is part of the following fields:
- Cardiology
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Question 73
Incorrect
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Which of the following is the mechanism of action of bivalirudin in acute coronary syndrome?
Your Answer:
Correct Answer: Reversible direct thrombin inhibitor
Explanation:Bivalirudin is a competitive, direct thrombin inhibitor. It inhibits both free and clot-bound thrombin and thrombin-induced platelet aggregation. Thrombin enables fibrinogen conversion to fibrin during the coagulation cascade. So inhibition of fibrinogen conversion to fibrin inhibits thrombus development.
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This question is part of the following fields:
- Cardiology
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Question 74
Incorrect
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A 70 yr. old male patient presented with increased difficulty in breathing during the last 4 months. He was diagnosed with mitral stenosis. On examination his BP was 120/80 mmHg and pulse rate was 68 bpm. There were bibasal crepitations on auscultation. He was on bisoprolol, frusemide and ISDN. From the given answers, what is the most likely indication of worsening of his mitral stenosis?
Your Answer:
Correct Answer: Haemoptysis
Explanation:Haemoptysis is a symptom which indicates the worsening of mitral stenosis. It occurs due to the rupture of pulmonary veins or the capillary system due to pulmonary venous hypertension. Elevated serum creatinine is seen in worsening aortic stenosis. Worsening of tricuspid regurgitation causes ascites and a pulsatile liver.
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This question is part of the following fields:
- Cardiology
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Question 75
Incorrect
-
From the following responses, what is the commonest cardiovascular abnormality associated with Marfan's syndrome of an adult?
Your Answer:
Correct Answer: Aortic root dilatation
Explanation:The main cardiovascular manifestations associated with Marfan’s syndrome are aortic dilatation and mitral valve prolapse.
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This question is part of the following fields:
- Cardiology
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Question 76
Incorrect
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A 30 yr. old male presented with exercise related syncope and dyspnoea for 2 weeks. His father passed away at the age of 40, due to sudden cardiac death. His ECG showed left ventricular hypertrophy with widespread T wave inversions. Which of the following is the most appropriate next investigation to confirm the diagnosis?
Your Answer:
Correct Answer: Transthoracic echo
Explanation:The most likely diagnosis is hypertrophic obstructive cardiomyopathy which is suggestive by the history, positive family history and ECG findings. Two-dimensional echocardiography is diagnostic for hypertrophic cardiomyopathy. In general, a summary of echocardiography findings includes abnormal systolic anterior leaflet motion of the mitral valve, LV hypertrophy, left atrial enlargement, small ventricular chamber size, septal hypertrophy with septal-to-free wall ratio greater than 1.4:1, mitral valve prolapse and mitral regurgitation, decreased midaortic flow, and partial systolic closure of the aortic valve in midsystole.
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This question is part of the following fields:
- Cardiology
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Question 77
Incorrect
-
A 48 yr. old male presented with exertional angina for 2 weeks. He has no significant past medical history or cardiac risk factors except a total cholesterol of 5.8 mmol/L. He has been already started on aspirin. Which of the following is the most suitable drug combination for him?
Your Answer:
Correct Answer: B-blocker and statin
Explanation:Beta blockers and calcium channel blockers have proven prognostic benefits. Nitrates don’t have any proven prognostic benefits. A statin is indicated for a patient with angina and cholesterol level of 5.5 to 8.5 to prevent risk of myocardial infarction. So the preferred combination from the given answers is beta blocker + statin.
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This question is part of the following fields:
- Cardiology
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Question 78
Incorrect
-
A 50 yr. old male with a history of type II diabetes mellitus and hypertension presented with exertional dyspnoea and chest pain for 2 weeks. On examination his blood pressure was 145/80 mmHg. On auscultation reversed splitting of the second heart sound and bibasal crepitations were detected. What would be the most likely finding on his ECG?
Your Answer:
Correct Answer: Left bundle branch block
Explanation:When closure of the pulmonary valve occurs before the aortic valve, reversed splitting occurs. The causes of reversed splitting are aortic stenosis, hypertrophic cardiomyopathy, left bundle branch block (LBBB), and a ventricular pacemaker.
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This question is part of the following fields:
- Cardiology
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Question 79
Incorrect
-
A 42 yr. old female presented with pain in her calves during walking which settled after resting. On examination there were orange colour deposits in the her palmar creases. Her fasting lipid profile showed a total cholesterol of 9.2 mmol/l (<5) and triglycerides of 7.0 mmol/l (<2). Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Type III hyperlipidaemia
Explanation:Palmar xanthomas are found in type III hyperlipoproteinemia. Her total cholesterol level and triglyceride level support the diagnosis.
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This question is part of the following fields:
- Cardiology
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Question 80
Incorrect
-
A 26 yr. old male was being investigated further following several hypertensive episodes. There was a marked difference in his systolic blood pressures between the right brachial and the right femoral arteries. Which of the following is most probable diagnosis?
Your Answer:
Correct Answer: Coarctation of the aorta
Explanation:From the given physical findings (the difference in BP between the radial and femoral arteries), the most probable diagnosis is coarctation of the aorta.
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This question is part of the following fields:
- Cardiology
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Question 81
Incorrect
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A 72 yr. old male presented to the Emergency Department with a broad complex tachycardia. Which of the following features is more suggestive that this has resulted because of a supraventricular tachycardia (SVT) rather than a ventricular tachycardia (VT)?
Your Answer:
Correct Answer: Absence of QRS concordance in chest leads on ECG
Explanation:To differentiate ventricular tachycardia (VT) from supraventricular tachycardia (SVT) with aberrant conduction the following electrocardiographic features should be looked for:
Evidence of preceding atrial activity for SVT. Oesophageal leads are helpful if P waves are hidden in the QRS complex.
QRS duration more than 140 ms for VT.
QRS morphology: Features of QRS morphology that favour SVT are RBBB or triphasic patterns like rSR in V1 and qRS in V6. Monophasic pattern like R or qR in V1 and rS or QS in V6 or multiple morphology QRS complexes favour VT.
AV dissociation for VT. -
This question is part of the following fields:
- Cardiology
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Question 82
Incorrect
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A 25 yr. old female presented with a history of sudden collapse. She had been playing netball and had suddenly collapsed. This collapse had been accompanied by a brief period of loss of consciousness. She experienced palpitations for a brief period prior to losing consciousness. On examination her BP was 120/70 mmHg and pulse rate was 72 bpm, which was regular. The rest of the examination was also normal. She had similar experience of collapse, about two years ago. She was well except for these two incidents and she has not been on any medication. All the investigations done at the first presentation (2 years ago), including FBC, ECG and echocardiography were normal. Her ECG done at this presentation revealed QT prolongation of 0.50 s. FBC, CXR and other investigations were normal. Which of the following is the best way of managing this patient?
Your Answer:
Correct Answer: Start on a beta-blocker
Explanation:Beta-blockers are drugs of choice for patients with LQTS. The protective effect of beta-blockers is related to their adrenergic blockade, which diminishes the risk of cardiac arrhythmias. They may also reduce the QT interval in some patients.
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This question is part of the following fields:
- Cardiology
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Question 83
Incorrect
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Which one of the following responses is the least likely to be associated with primary pulmonary hypertension?
Your Answer:
Correct Answer: Recurrent pulmonary embolism
Explanation:Connective-tissue diseases, liver cirrhosis, exposure to anorexigens and likely other alpha-adrenergic stimulants [e.g., cocaine, amphetamines] and HIV infection are associated with primary pulmonary hypertension. Recurrent pulmonary emboli, chronic lung diseases, left heart diseases are causes for secondary pulmonary hypertension. Pulmonary vascular hypertension after use of fenfluramine is rarely reported.
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This question is part of the following fields:
- Cardiology
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Question 84
Incorrect
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A 20 yr. old male presented after an episode where he had collapsed. This was the second time he has collapsed during the past 3 weeks. His father passed away at the age of 40 due to sudden cardiac death. Echocardiography showed evidence of hypertrophic cardiomyopathy. His 24 hr ECG revealed several short runs of non sustained ventricular tachycardia (VT). Which of the following is the most appropriate management for this patient?
Your Answer:
Correct Answer: Implantable cardiovertor defibrillator
Explanation:This patient has a high risk of sudden cardiac death due to a strong family history and non sustained VT. So the most appropriate management is implantable cardiovertor defibrillator.
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This question is part of the following fields:
- Cardiology
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Question 85
Incorrect
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A 60 yr. old female presented with difficulty in breathing. What is the clinical sign that will indicate the presence of established pulmonary hypertension?
Your Answer:
Correct Answer: Raised jugular venous pressure
Explanation:A prominent A wave is observed in the jugular venous pulse and this indicates the presence of established pulmonary hypertension. In addition the pulmonic component of the second heart sound (P2) may be increased and the P2 may demonstrate fixed or paradoxical splitting. The signs of right ventricular failure include a high-pitched systolic murmur of tricuspid regurgitation, hepatomegaly, a pulsatile liver, ascites, and peripheral oedema.
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This question is part of the following fields:
- Cardiology
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Question 86
Incorrect
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A 40 yr. old female presented with palmar xanthomas and tuberoeruptive xanthomas on her elbows and knees. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Type III hyperlipoproteinaemia
Explanation:Palmar xanthomas and tuberoeruptive xanthomas are found in type III hyperlipoproteinemia (dysbetalipoproteinemia,broad-beta disease, remnant removal disease)
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This question is part of the following fields:
- Cardiology
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Question 87
Incorrect
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A 65 yr. old woman was referred due to a pulse rate of 40 bpm. Which of the following answers is associated with the least risk of asystole?
Your Answer:
Correct Answer: Complete heart block with a narrow complex QRS
Explanation:From the given answers, complete heart block with a narrow complex QRS complex is associated with the least risk of asystole. Transvenous pacing is indicated by the other given responses.
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This question is part of the following fields:
- Cardiology
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Question 88
Incorrect
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A 55 yr. old female with a history of hypertension presented with severe central chest pain for the past one hour, associated with sweating and vomiting. Her ECG showed ST elevation myocardial infarction, evident in leads V2-V4. Which of the following is an absolute contraindication for thrombolysis?
Your Answer:
Correct Answer: Intracranial neoplasm
Explanation:Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial haemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months -
This question is part of the following fields:
- Cardiology
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Question 89
Incorrect
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Which of the following features of the jugular venous waveform indicates the closure of the tricuspid valve?
Your Answer:
Correct Answer: c wave
Explanation:The a wave indicates atrial contraction. The c wave indicates ventricular contraction and resulting bulging of the tricuspid valve into the right atrium during isovolumetric systole. The v wave indicates venous filling. The x descent indicates the atrium relaxation and the movement of tricuspid valve downward. The y descent indicates the filling of the ventricle after the opening of the tricuspid valve.
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This question is part of the following fields:
- Cardiology
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Question 90
Incorrect
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A 18 yr. old male was screened for hypertrophic cardiomyopathy (HOCM) as his brother had the same condition. What is the echocardiographic finding that is related to the highest risk of sudden cardiac death?
Your Answer:
Correct Answer: Significant thickening of the interventricular septum
Explanation:There are five prognostic factors which indicate poor prognosis in HOCM:
-family history of HOCM-related sudden cardiac death
-unexplained recent syncope
-large left ventricular wall thickness (MLVWT ≥ 30 mm)
-multiple bursts of nsVT on ambulatory electrocardiography
-hypotensive or attenuated blood pressure response to exercise -
This question is part of the following fields:
- Cardiology
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SESSION STATS - PERFORMANCE PER SPECIALTY
