Medicine Cardiology Self Assessment PDF

DE Newby, NR Grubb 16 Cardiology Multiple Choice Questions 16.1. A 55 year old man with a history of poorly elevated jugular venous pressure (JVP). Which controlled hypertension prese...

DE Newby, NR Grubb 16 Cardiology Multiple Choice Questions 16.1. A 55 year old man with a history of poorly elevated jugular venous pressure (JVP). Which controlled hypertension presents with a history of the following conditions is most likely to of sudden-onset central chest pain. There are explain this physical finding? no diagnostic electrocardiogram (ECG) A. Aortic stenosis abnormalities, and an interval troponin B. Dehydration concentration is not diagnostic of myocardial C. Exacerbation of asthma infarction. What diagnosis should be confirmed D. Increased left atrial pressure or excluded next? E. Recurrent pulmonary embolism A. Anxiety B. Aortic dissection 16.5. A 56 year old man presents with a history C. Myocarditis of headache. He is noted to have a loud D. Pericarditis second heart sound on auscultation. Which of E. Pneumothorax the following pathologies could explain this finding? 16.2. The term ‘orthopnoea’ refers to A. Aortic incompetence breathlessness (dyspnoea) in a particular B. Essential hypertension situation. Which answer below describes that C. Mechanical mitral valve replacement situation? D. Mitral incompetence A. After several hours of sleep E. Postural hypotension B. Due to asthma C. Immediately on lying flat 16.6. Which of the following pathologies can be D. On exertion associated with an early diastolic murmur? E. On sitting upright A. Long QT syndrome type 1 B. Marfan’s syndrome 16.3. A 75 year old woman presents to her C. Mitral valve prolapse family physician with a 24-hour history of rapid, D. Myotonic dystrophy irregular palpitations accompanied by fatigue. In E. Wolff–Parkinson–White syndrome an elderly patient, what is the most likely cause of palpitations? 16.7. An 80 year old woman with a history of A. Atrial ectopic (premature) beats palpitation presents with a painful left leg. On B. Atrial fibrillation examination, pulse rate is 80 beats/min and C. Supraventricular tachycardia irregular, blood pressure (BP) 170/96 mmHg. D. Ventricular ectopic (premature) beats The left leg is pale, cold, and sensation is E. Ventricular tachycardia reduced. The popliteal, dorsalis pedis and posterior tibial pulses cannot be felt. Her only 16.4. A 74 year old woman presents with regular medications are aspirin and digoxin. breathlessness. She is found to have an What is the most likely diagnosis?  CARDIOLOGY A. Acute arterial plaque rupture with lower limb A. A normal baseline troponin and elevated ischaemia 6-hour troponin level is suspicious of B. Deep venous thrombosis with secondary myocardial infarction reduction of arterial blood flow B. A normal ECG excludes myocardial infarction C. Dissection of the femoral artery due to C. A normal initial troponin level excludes uncontrolled hypertension myocardial infarction D. Peripheral embolism with lower limb ischaemia D. Failure of chest pain to resolve with nitrates E. Reduced lower limb perfusion due to cardiac confirms myocardial infarction failure E. T-wave inversion on the ECG confirms myocardial infarction 16.8. A 50 year old man is assessed because i i 16.12. A 72 year old hypertensive woman symptoms. Examination findings are presents with a history of sudden-onset, rapid, tachycardia (heart rate 105 beats/min), and a irregular palpitation. She has had several large pulse pressure, BP 140/45 mmHg. Initially i i i it was thought a murmur was present but have resolved within 1 hour. She feels tired and repeat examination reveals no murmur. slightly lightheaded during episodes. From this Investigations reveal no evidence of chest or history, which of the following most likely urinary infection. What are these findings most explains her symptoms? compatible with? A. Atrial fibrillation A. Acute myocarditis B. Sinus arrhythmia B. Acute viral pericarditis C. Supraventricular tachycardia C. Infective endocarditis affecting the aortic valve D. Ventricular ectopic beats (extrasystoles) D. Infective endocarditis affecting the tricuspid E. Ventricular tachycardia valve E. 16.13. In the management of cardiac arrest, 16 which of the following most accurately 16.9. You assess a 62 year old woman 2 days describes basic life support (BLS)? after treatment for anterior myocardial A. Administration of intravenous drugs and infarction. On examination she is tachycardic external defibrillation (the two ‘D’s) and tachypnoeic, and has a harsh systolic B. External cardiac massage only murmur radiating to the right side of the chest. C. Support of airway, breathing and circulation There are fine inspiratory crepitations audible at (ABC) the lung bases. What is the most likely D. Support of airway, breathing and circulation, explanation for these findings? and assessment of disability and exposure A. Acute aortic incompetence (ABCDE) B. Left ventricular free wall rupture E. Support of airway, breathing and circulation, C. Papillary muscle rupture and mitral and assessment of disability and exposure, incompetence treatment of fibrillation (ABCDEF) D. Post-infarction pericarditis with pericardial rub E. Rupture of the interventricular septum 16.14. Which of the following statements is true of a pulseless electrical activity (PEA) cardiac 16.10. Which of the following physical signs is arrest? associated with left ventricular failure? A. Cardiopulmonary resuscitation (CPR) should A. A gallop rhythm with a fourth heart sound be carried out for 1 minute before the rhythm B. A gallop rhythm with a third heart sound is reassessed C. A loud second heart sound B. Intravenous amiodarone will restore cardiac D. A quiet first heart sound output E. Fixed splitting of the second heart sound C. It is initially managed with immediate defibrillation 16.11. A 55 year old man with type 2 diabetes D. Reversible causes include hyperthyroidism presents with a 1-hour history of severe central and hypercalcaemia chest pain. Which of the following statements E. Reversible causes include hypothermia and is true? hypoxia  CARDIOLOGY 16.15. A 65 year old female presents with chest 16.19. β-Adrenoceptor antagonists (β-blockers) pain, and the 12-lead ECG shows evidence of are used in which of the following situations? acute inferior myocardial infarction complicated A. Acute left ventricular failure by hypotension. An echocardiogram is B. Cardiac failure associated with bradycardia performed and shows markedly reduced C. Cardiogenic shock movement of the right ventricular walls, D. Chronic left ventricular systolic dysfunction indicating that right ventricular infarction has E. High-output cardiac failure occurred. Left ventricular function is only mildly impaired. Which of the following physical signs 16.20. A 71 year old woman with a history of would be expected in this situation? hypertension presents with fatigue and rapid, A. Tachycardia, a late systolic murmur and irregular palpitations. She normally takes ascites enalapril for blood pressure control. Clinical B. Tachycardia, and absent jugular venous examination reveals an irregularly irregular pulse because of inability to develop right pulse, rate 125 beats/min, and BP heart pressure 128/86 mmHg. Cardiovascular examination is C. Tachycardia, acute development of otherwise normal. A 12-lead ECG is performed, peripheral oedema and acute ascites which shows atrial fibrillation with poor D. Tachycardia, basal crepitations and a third ventricular rate control, but no other heart sound abnormality. Which of the following drugs is the E. Tachycardia, elevated jugular venous pulse most suitable agent to control heart rate in this due to failure of right ventricular pump patient? function, and hepatomegaly A. Adenosine B. Amiodarone 16.16. What relationship does Starling’s Law of C. β-blocker the heart describe? D. Flecainide A. Between blood pressure and cardiac output E. Lidocaine B. Between cardiac filling and blood pressure C. Between cardiac filling and cardiac output 16.21. An 85 year old man presents with a D. Between heart rate and blood pressure 6-month history of sudden episodes of E. Between heart rate and cardiac output lightheadedness, which last up to 15 seconds. He is admitted to hospital with an episode of 16.17. What underlying pathophysiological syncope resulting in facial injury. Examine the changes is chronic cardiac failure associated rhythm strip below. Which conduction with? abnormality does this show? A. Activation of the renin–angiotensin– A. Complete (third-degree) AV block aldosterone system (RAAS) B. Left bundle branch block B. Inhibition of the RAAS C. i C. Inhibition of the sympathetic nervous system D. Sinus bradycardia D. Reduced production of brain natriuretic E. i peptide (BNP) AV block E. Systemic vasodilatation 16.22. Which of the following rhythms is NOT 16.18. Loop diuretics such as furosemide and commonly associated with sick sinus syndrome bumetanide have which of the following (sinoatrial disease)? effects? A. Atrial fibrillation A. Diuresis due to inhibition of potassium and B. Atrial tachycardia water reabsorption C. Sinus bradycardia B. Diuresis due to inhibition of sodium and D. Sinus pauses water reabsorption E. Ventricular tachycardia C. Diuresis due to inhibition of water reabsorption only D. Increased serum potassium levels due to enhanced distal tubule function E. Osmotic diuresis Fig. 16.21  CARDIOLOGY 16.23. A 75 year old woman has a history of A. A 26 year old man with polymorphic hypertension and diabetes. She presents with ventricular tachycardia (torsades de pointes) atrial fibrillation. What is her CHA2DS2-VASc occurring after cocaine use score? B. A 48 year old man who presents with acute A. 2 inferior myocardial infarction complicated B. within the first 6 hours by ventricular C. 4 fibrillation D. 5 C. A 55 year old woman with syncope; ECG E. 6 monitoring shows sinus rhythm with third-degree atrioventricular block 16.24. Which of the following drugs is known to D. A 75 year old man with syncope; ambulatory be effective in preventing stroke in patients with ECG shows sinus bradycardia and daytime atrial fibrillation? sinus pauses of up to 5 seconds E. An 80 year old man with a history of anterior A. Amiodarone myocardial infarction 6 months previously; he B. Apixaban is fit, has never experienced arrhythmia, and C. Aspirin a cardiac magnetic resonance scan shows D. β-blocker poor left ventricular function (left ventricular E. Clopidogrel ejection fraction 28%) 16.25. The ECG below shows a regular, narrow 16.28. A 17 year old male presents to the complex tachycardia in a patient presenting emergency department with an episode of with sudden-onset, rapid palpitation. Which of collapse. Witnesses report he became extremely the following should be used first in attempting blue at the time of collapse, which occurred on to terminate this rhythm? walking. The patient tells you he has a history of A. Direct current cardioversion congenital heart disease. On examination you 16 B. Intravenous adenosine note he is centrally cyanosed. Which of the C. Intravenous β-blocker following congenital conditions is the most likely D. Oral β-blocker explanation for this presentation? E. Vagal manoeuvres, e.g. Valsalva manoeuvre A. Coarctation of the aorta B. Congenital heart block 16.26. For which of the following scenarios C. Patent foramen ovale would a permanent pacemaker be an D. Tetralogy of Fallot appropriate treatment? E. Wolff–Parkinson–White syndrome A. Paroxysmal atrial fibrillation B. Prevention of sudden death due to 16.29. Which of the following is true of ventricular fibrillation Eisenmenger’s syndrome? C. Sick sinus syndrome associated with syncope D. Sinus bradycardia in an athlete A. Breathlessness and fatigue are uncommon E. Supraventricular tachycardia symptoms B. It occurs in patients with patent foramen ovale 16.27. Which of the following patients is a C. Left to right shunting occurs because of suitable candidate for an implantable cardiac pulmonary hypertension defibrillator? D. Life expectancy is markedly reduced E. Patients are peripherally but not centrally cyanosed 16.30. A 48 year old woman registers with a new family physician. She tells the doctor she had a small hole in her heart from birth but that it did not require any treatment. On examination, pulse is 70 beats/min and regular; BP 122/76 mmHg. You detect a loud, high-pitched systolic murmur at the left sternal Fig. 16.25 border, accompanied by a thrill. Which of the  CARDIOLOGY following conditions would explain the history D. Obesity and physical findings? E. Recreational cannabis use A. Anterior mitral leaflet prolapse B. Atrial septal defect 16.35. By which of the following features is C. Patent foramen ovale hypertrophic cardiomyopathy usually D. Persistent ductus arteriosus characterised? E. Ventricular septal defect A. Asymmetric left ventricular hypertrophy with marked thickening of the interventricular 16.31. A 21 year old man presents with a recent septum i i i i i ii B. Asymmetric left ventricular hypertrophy with characterised by fever, myalgia and headache. marked thickening of the anterior left He develops pleuritic-type chest discomfort and ventricular wall breathlessness. On examination, pulse is C. Hypertrophy of both atria and both 105 beats/min and regular; BP 105/60 mmHg. ventricles The JVP is not elevated. Heart sounds 1 and 2 D. Hypertrophy of the left ventricle and atrophy are present with a loud to-and-fro harsh sound of the right ventricle present in systole and diastole. Which of the E. Symmetrical left ventricular hypertrophy following conditions explains this clinical presentation? 16.36. Cardiac transplantation is considered in A. Acute viral pericarditis which group of patients with cardiomyopathy? B. Aortic valve endocarditis A. Asymptomatic patients C. Mitral valve endocarditis B. Frail elderly patients with end-stage heart D. Persistent ductus arteriosus failure E. Pulmonary embolism C. Patients who do not wish to take life-long medication 16.32. What is the appropriate initial treatment D. Patients who have poor quality of life despite for the symptoms of acute pericarditis? optimal drug therapy A. Intravenous glucocorticoids E. Patients who have symptoms but good B. Intravenous morphine quality of life on optimal drug therapy C. Oral amiodarone D. Oral aspirin 16.37. A 48 year old woman with no significant E. Rectal diclofenac previous medical history collapses while running a marathon. Despite attempts at resuscitation, 16.33. Which of the following best describes she does not survive. Postmortem examination dilated cardiomyopathy? reveals asymmetric left ventricular hypertrophy A. A disease of the myocardium characterised with disproportionate thickening of the by chamber enlargement and thinning of the interventricular septum. A postmortem left and right ventricular walls diagnosis of hypertrophic cardiomyopathy is B. A disease of the myocardium characterised made. What is the most likely cause of this by disproportionate thickening of the patient’s sudden collapse? interventricular septum A. Atrial fibrillation C. A disease of the myocardium characterised B. Left ventricular failure by infiltration of myocardial tissue resulting in C. Pulmonary embolism restricted contraction and relaxation D. Right ventricular failure D. Isolated dilatation of the atria, causing atrial E. Ventricular arrhythmia fibrillation E. Isolated dilatation of the right ventricle, 16.38. causing ventricular tachycardia diagnosed with dilated cardiomyopathy. Her diagnosis was made with echocardiography, 16.34. Which of the following is a cause of which showed moderate left ventricular dilated cardiomyopathy? dilatation and impairment. She has noticed A. A high-cholesterol diet herself becoming increasingly fatigued on B. Heavy alcohol consumption moderate exertion. Her younger sister died C. Mutation in cardiac sodium channel gene suddenly the previous year and she is very  CARDIOLOGY worried about the risk of sudden death. Which 16.43. A 75 year old male smoker presents of the following treatments is known to reduce with a 6-week history of progressive exertional her risk of sudden death? breathlessness and fatigue. Latterly he has A. Aspirin noticed his ankles swelling in the afternoon. B. β-blocker (e.g. metoprolol) On examination, pulse is 100 beats/min and C. Calcium channel blocker (e.g. verapamil) regular; BP 92/60 mmHg. The JVP is elevated D. Loop diuretic (e.g. furosemide) and rises on inspiration. Heart sounds are quiet E. Percutaneous coronary intervention (PCI) and there are no added sounds. There is bilateral pitting oedema to the knees. A chest 16.39. A 55 year old woman presents with a X-ray is requested, which shows apparent history of acute, severe, constricting central cardiomegaly with a globular cardiac chest pain associated with anterior ST segment silhouette. You suspect a possible pericardial elevation on the 12-lead ECG. She immediately effusion. Which of the following statements undergoes coronary angiography, which shows is true? no evidence of coronary artery disease and no A. A large effusion can be a sign of coronary occlusion. An echocardiogram shows malignancy left ventricular apical dilatation, with normal left B. A pericardial rub is always heard if the ventricular basal contraction. Which of the effusion is large following factors is most likely to have C. An ECG is the best investigation to confirm precipitated this illness? the diagnosis A. Acute emotional stress D. High-dose diuretic therapy will resolve the B. Cigarette smoking pericardial effusion C. Excessive alcohol consumption E. In symptomatic patients, cardiac surgery is D. Genetic factors required to remove the pericardial fluid E. Viral infection 16.44. An 18 year old man presents with 16 16.40. Which of the following is associated with sudden onset of sharp chest pain. excessive alcohol consumption? The pain is made worse by deep inspiration A. Atrial fibrillation or lying down flat. It is relieved by sitting B. Diverticulitis forward and taking shallow breaths. He C. Hypertrophic cardiomyopathy presents to the emergency department and D. Hypotension an ECG is recorded because the attending E. Supraventricular tachycardia doctor suspects acute pericarditis. What is the most specific ECG change in 16.41. Atrial myxoma is the most common pericarditis? primary cardiac tumour. Which of the following A. PR interval prolongation is true of atrial myxoma? B. PR segment depression A. Atrial myxomas are usually malignant C. ST depression B. It occurs more commonly in the right atrium D. ST elevation than in the left atrium E. T-wave inversion C. Surgery is not indicated because atrial myxomas are benign 16.45. A 46 year old man has recently fractured D. Surgery is usually indicated to prevent his leg, which is in a plaster cast. He suddenly embolic complications such as stroke becomes very breathless, unwell and collapses. E. The tumour commonly obstructs the aortic The attending doctor suspects a pulmonary valve embolus from a deep vein thrombosis. The doctor performs an ECG. What is the most 16.42. Which of the following conditions may common ECG change in patients with result in chronic pericardial constriction? pulmonary embolism? A. Acute myocardial infarction A. Anterior T-wave inversion B. Dilated cardiomyopathy B. Atrial fibrillation C. Excessive alcohol consumption C. D. Osteoarthritis D. Sinus tachycardia E. Tuberculosis E. ST elevation  CARDIOLOGY 16.46. In patients with a pericardial effusion, 16.51. An 80 year old woman presents with what is the most important clinical sign to shortness of breath and swollen ankles. Her determine whether there is cardiac tamponade? ECG showed some poor R-wave progression. A. Cyanosis She was referred for an echocardiogram and B. Haematuria was found to have a high ejection fraction. C. Peripheral oedema Which of these conditions is the most likely D. Pulsus paradoxus cause of her presentation? E. Raised JVP A. Acute myocarditis B. Aortic stenosis 16.47. The following medical treatments are all C. Dilated cardiomyopathy associated with improved symptoms in patients D. Ischaemic cardiomyopathy with extensive with heart failure due to left ventricular systolic infarction dysfunction. However, which of the treatments E. Restrictive cardiomyopathy has NOT been shown to also improve survival? A. Bisoprolol 16.52. Neuroendocrine system activation is a B. Enalapril feature of heart failure. Abnormalities of which C. Furosemide hormone can cause heart failure rather than D. Sacubitril–valsartan result from heart failure? E. Spironolactone A. Aldosterone B. Angiotensin II 16.48. Which of the following antiplatelet drugs C. Catecholamines is a phosphodiesterase inhibitor? D. Thyroxine A. Cangrelor E. Vasopressin (antidiuretic hormone, ADH) B. Clopidogrel C. Dipyridamole 16.53. Which of the following biomarkers is a D. Prasugrel structural protein rather than a cardiac E. Ticagrelor A. Aspartate aminotransferase 16.49. A 54 year old security guard who is B. Creatine kinase obese and enjoys drinking alcohol and cigarette C. Creatine kinase MB smoking with his friends has a diet high in D. Lactate dehydrogenase saturated fats. He has an acute myocardial E. Troponin I infarction. Which lifestyle risk factor has the strongest association with myocardial 16.54. A patient has a stent placed in his right infarction? coronary artery. On return to the ward, he gets A. Excess alcohol severe chest pain and becomes very unwell. B. High-saturated fat diet The nurse undertakes an ECG and calls the C. Obesity interventional cardiologist to review the patient D. Sedentary activity because she is concerned that he has a E. Smoking thrombosed stent. What ECG features would suggest the stent has become occluded? 16.50. A. Anterior T-wave inversion of chest pain whilst out walking in a remote B. Atrial fibrillation island of Scotland. He attends the local hospital C. Atrioventricular block and is found to have ST segment elevation D. ST elevation in I, aVL and V6 myocardial infarction. Which treatment has the E. ST elevation in V2–V5 strongest time-dependent benefit (i.e. the quicker received, the better the outcome) for 16.55. A 72 year old woman has had ST segment elevation myocardial infarction? ‘indigestion’ for 4 days with vomiting and A. Aspirin sweating. She presents to the emergency B. β-blocker department where a delayed presentation inferior C. Heparin ST segment elevation myocardial infarction is D. Percutaneous coronary intervention diagnosed. She has already developed Q E. Tissue plasminogen activator waves in leads II, III and aVF. One day after  CARDIOLOGY admission to hospital, she suddenly deteriorates C. Smoking cessation with severe breathlessness, low blood pressure D. Statin and sudden onset of pulmonary oedema. What E. Warfarin is the most likely cause? A. Acute papillary muscle rupture 16.60. Limb ischaemia can take many forms B. Acute pericarditis and has varied causes. This may result in C. Atrial septal defect sudden acute vessel occlusion from arterial D. Free wall rupture spasm or thrombosis, or more chronic E. Mural thrombus processes. What is the most likely underlying cause of severe limb ischaemia in an otherwise 16.56. A patient admitted to the emergency i department with severe chest pain and ST A. Atherosclerosis segment deviation suddenly collapses and is B. Atrial fibrillation found not to be breathing or have a pulse. C. Buerger’s disease A cardiac arrest call is made. What is the most D. Diabetes mellitus likely cause of his collapse? E. Raynaud’s disease A. Asystole B. Complete heart block 16.61. A 65 year old man with known C. Free wall rupture hypertension presents with severe central chest D. Pulseless electrical activity pain that radiates between his shoulder blades. E. Ventricular fibrillation He is sweaty with a BP of 200/100 mmHg in his right arm, a pale left arm and an ECG 16.57. A 75 year old man is incidentally found showing sinus tachycardia. His chest X-ray to have a pulsatile swelling in his abdomen on shows mediastinal widening and a computed a routine health check. He is sent for an tomography scan shows a type A aortic abdominal ultrasound scan, which confirms the dissection. Which of the following is known to 16 presence of an abdominal aortic aneurysm. reduce mortality? Which risk factor is protective against the A. Anticoagulation formation and expansion of an abdominal aortic B. Control of the blood pressure aneurysm? C. Emergency repair of the ascending aorta A. Diabetes mellitus D. Intravenous β-blockade B. Family history of aneurysm disease E. Prevention of limb or renal ischaemia C. Hypercholesterolaemia D. Hypertension 16.62. A short young woman presents with E. Smoking severe chest pain, vomiting and a sinus tachycardia. She is in the last trimester of 16.58. pregnancy and has had normal blood pressure with calf pain on walking and is referred to a and observations at antenatal care. She is vascular surgeon for assessment. Which clinical admitted for observation but is later found feature would be most reassuring? collapsed and in cardiac arrest. Despite A. Capillary refill < 2 seconds attempts at resuscitation, mother and child die. B. Cold temperature Postmortem reveals an aortic dissection. What C. Hair loss is the most likely underlying cause for the D. Pallor dissection? E. Pulselessness A. Coarctation of the aorta B. Intramural haematoma 16.59. A 65 year old smoker with hypertension C. Marfan’s syndrome is found to have an abdominal aortic aneurysm D. Pregnancy on population screening with ultrasound. Which E. Undiagnosed hypertension intervention will most reduce his future risk of aortic aneurysm rupture? 16.63. A 50 year old woman with diabetes, who A. i i i smokes, presents with jaw pain, severe nausea, inhibitor autonomic arousal and vomiting. An ECG is B. β-blocker performed in the emergency department and 140 CARDIOLOGY shows anterior ST segment elevation. What is D. Poor adherence with medication the best immediate reperfusion therapy? E. Renal failure A. Coronary artery bypass graft surgery B. Morphine 16.67. An 18 year old woman presents with a C. Primary percutaneous coronary intervention sore throat and suspected acute rheumatic D. Streptokinase fever. Which of the following is a minor E. Tissue plasminogen activator manifestation of acute rheumatic fever? A. Carditis 16.64. An 81 year old non-smoker presents with B. Chorea chest pain and an ECG with ST segment C. Erythema marginatum depression. His troponin concentration is D. Raised C-reactive protein 456 ng/L (reference range < i E. Subcutaneous nodules treated with an angioplasty and stent 2 days later. At the same time, a 60 year old smoker 16.68. An 18 year old woman has a raised with diabetes has a large anterior ST segment C-reactive protein, a rash consistent with elevation myocardial infarction, has ventricular erythema marginatum and pyrexia. However, fibrillation in the ambulance and has immediate the clinician remains uncertain about the defibrillation. He undergoes immediate diagnosis of acute rheumatic fever. Rapid percutaneous coronary intervention on arrival at response to which treatment will help to hospital and has a troponin concentration of confirm the diagnosis? > 50 000 ng/L. A medical student asks who has A. Aspirin the better prognosis. What is the biggest B. Bed rest predictor of mortality following acute myocardial C. Diuretics infarction? D. Glucocorticoids A. Age E. High-dose antibiotics B. Cardiac arrest C. ECG changes 16.69. i D. Smoking symptoms of breathlessness on exertion, a E. Troponin concentration malar flush and has a past history of rheumatic fever. She is in sinus rhythm and has an 16.65. x i echocardiogram that confirms mitral stenosis. reproducible BP of 180/100 mmHg. She is Which physical sign is she likely to have? referred for assessment in the clinic. You A. Ejection systolic murmur perform a range of tests to determine B. Mid-systolic click whether there is an underlying cause for her C. Pre-systolic accentuation hypertension. What is the commonest cause of D. Quiet second heart sound secondary hypertension? E. Thrusting apex beat A. Congenital adrenal hyperplasia B. Conn’s syndrome 16.70. An 80 year old man presents with an C. Phaeochromocytoma incidental ejection systolic murmur. His family D. Renal disease physician notices a parasternal thrill. What is E. Thyrotoxicosis the likely underlying reason for the thrill? A. Aortic stenosis 16.66. A 60 year old man is referred by his B. Large atrial septal defect family physician because despite four drugs he C. Mitral stenosis continues to have uncontrolled blood pressure. D. Pulmonary hypertension The doctor feels that the patient needs further E. Right ventricular hypertrophy investigation for a potential secondary cause of hypertension. What is the commonest cause of 16.71. i poorly controlled hypertension? health check with his employers. He is found to A. Conn’s syndrome have a murmur, isolated systolic hypertension B. Glucocorticoid-suppressible (180/60 mmHg) and left ventricular hypertrophy hyperaldosteronism on his ECG. A significant regurgitant blood C. Hyper-reninaemia flow is noticed across the aortic valve on  CARDIOLOGY echocardiogram. Which of the following clinical In what manner is hypertrophic cardiomyopathy signs is likely to be observed? commonly inherited? A. Crescendo–decrescendo murmur A. Autosomal dominant B. Palpable thrill in the aortic area B. Autosomal recessive C. Prominent pulsation in the neck (de Musset’s C. Never inherited sign) D. X-linked dominant D. Quiet second heart sound E. X-linked recessive E. Slow rising pulse 16.76. i 16.72. A 65 year old man presents with a evaluation because she is very tall, has 4-week history of general malaise and lethargy. problems with her vision and has a heart He has had two courses of antibiotics that murmur. Her family physician is concerned that have temporarily improved his symptoms but she may have Marfan’s syndrome. What he continues to feel worse over time. His family structural gene is associated with an physician notices he has become anaemic. He abnormality in Marfan’s syndrome? attends the emergency department and he is A. Fibrillin admitted to hospital with a fever. He has some B. Myosin heavy chain blood cultures taken and he undergoes an C. Myosin-binding protein echocardiogram, which shows a mass on his D. Titan mitral valve. What is the most likely organism E. Troponin that will be grown from his blood cultures? A. Staphylococcus aureus 16.77. A patient presents with an incidental B. Staphylococcus epidermidis finding of a mass in the left atrium whilst C. Streptococcus faecalis undergoing an echocardiogram for D. Streptococcus gallolyticus hypertension. What is the most likely cardiac E. Viridans streptococci tumour in this situation? 16 A. Angiosarcoma 16.73. Considering the patient in Question B. Atrial myxoma 16.72, before the blood culture results are C. Fibroelastoma known, the junior doctor reviews the 65 year D. Fibroma old man and examines him for evidence of E. Lipoma endocarditis. What is the commonest sign that the doctor is likely to find? 16.78. x i A. Haematuria anterior myocardial infarction and has received B. Osler’s nodes antiplatelet, anticoagulant and statin therapy. C. Roth’s spots He is referred for an echocardiogram. What will D. Splinter haemorrhages transthoracic echocardiography most usefully E. Subconjunctival haemorrhages assess in this setting? A. Cardiac arrhythmia 16.74. Considering the patient in Questions B. Future prognosis C. Left ventricular function and the presence of viridans streptococci. What is the most mural thrombus appropriate antibiotic regime to commence the D. Myocardial scar formation patient on? E. Thrombus in the left atrium A. Intravenous ampicillin and gentamicin B. i ii i i 16.79. The man with an extensive anterior C. Intravenous flucloxacillin myocardial infarction in Question 16.78 D. Intravenous vancomycin and gentamicin undergoes coronary angiography and is found E. i ii to have coronary artery disease. Which features on angiography predict the best outcome/ 16.75. An army recruit is referred for improvements with coronary artery bypass graft assessment because there is a family history of surgery? sudden cardiac death and an uncle was A. Diabetes mellitus and diffuse three-vessel diagnosed with hypertrophic cardiomyopathy. coronary heart disease 142 CARDIOLOGY B. Left main stem stenosis and significant left (reference range < i ventricular systolic dysfunction following treatments is likely to worsen his C. Severe proximal disease of the left anterior prognosis? descending coronary artery A. Aspirin D. Three-vessel coronary heart disease with B. Fondaparinux good left ventricular function C. Intravenous tissue plasminogen activator E. Two-vessel coronary heart disease (tPA) D. Metoprolol 16.80. The man with an extensive anterior E. Ticagrelor myocardial infarction in Questions 16.78 and 16.79 has left main stem and triple-vessel 16.84. An anaesthetist is seeking advice disease and is referred for coronary artery regarding a patient with coronary heart disease, bypass graft surgery. However, the surgeon is diabetes mellitus and a murmur. Which of the concerned that the anterior wall is completely following is NOT a significant risk factor for infarcted and is no longer viable. The surgeon perioperative myocardial infarction during wants to know if the anterior wall has significant non-cardiac surgery? amounts of scar tissue. Which imaging modality A. Aortic stenosis with a peak gradient of is best to identify the scar of acute myocardial 25 mmHg infarction? B. Diabetes mellitus treated with insulin and A. Computed tomography associated with renal failure B. Coronary angiography C. Recent (within 4 weeks) stenting of a severe C. Echocardiography proximal stenosis in the left anterior D. MRI descending coronary artery E. Stress echocardiography D. Recent acute coronary syndrome E. Severe left ventricular dysfunction 16.81. with acute pulmonary oedema, BP of 16.85. A 67 year old woman presents with 180/100 mmHg and a SaO2 of 85%. Which predictable exertional angina pectoris when treatment is UNLIKELY to be helpful in this climbing steep inclines. She has been setting? commenced on aspirin, statin and a β-blocker. A. Furosemide She attends your clinic for assessment. Which B. Intravenous dobutamine of the following suggests the patient is at low C. Intravenous nitrates risk of future events? D. Non-invasive ventilation A. Poor exercise tolerance E. Supplementary oxygen therapy B. Poor left ventricular function C. Post-infarct angina 16.82. i i D. Recent onset of symptoms of breast cancer is referred with a gradual E. i i onset of breathlessness. An echocardiogram the Bruce Protocol demonstrates a dilated poorly contracting left ventricle. You wish to investigate potential 16.86. You review a 50 year old smoker 2 causes of her dilated cardiomyopathy. Which of months after successful treatment for a the following would be an irreversible cause of myocardial infarction. Which intervention has her dilated cardiomyopathy? the greatest benefit to prevent a recurrence of A. Alcohol excess myocardial infarction? B. Anthracycline chemotherapy A. ACE inhibitor therapy C. Haemochromatosis B. Aspirin D. Hypothyroidism C. Regular and frequent aerobic exercise E. Thyrotoxicosis D. Smoking cessation E. Statin therapy 16.83. A 56 year old man presents with sudden onset of chest pain radiating down his left arm, ST segment depression of the ECG and a i i  CARDIOLOGY Answers 16.1. Answer: B. hypertension), the second heart sound may In a patient with poorly controlled hypertension, be loud. Postural hypotension will have little aortic dissection should be considered as a effect on the intensity of heart sounds at rest. potential cause of acute chest pain. While Aortic incompetence is often associated interscapular pain is a common feature of acute with a quiet second heart sound, and mitral aortic dissection, the presentation is highly incompetence with a quiet or absent first heart variable and central chest pain commonly sound. A mechanical mitral valve replacement occurs. If antiplatelet or antithrombotic drugs will produce a loud mechanical first heart are given before excluding this diagnosis, fatal sound. bleeding may occur. 16.6. Answer: B. 16.2. Answer: C. Marfan’s syndrome is a connective tissue Orthopnoea refers to breathlessness occurring disorder that is associated with abnormal immediately on lying flat, whereas the term production of elastic tissues. This can affect the ‘paroxysmal nocturnal dyspnoea’ refers to aorta, aortic root and aortic valve. Aortic root sudden episodes of breathlessness occurring dilatation can lead to aortic regurgitation and is at night-time. It can occur with respiratory also associated with increased risk of aortic pathologies such as chronic obstructive dissection. Aortic regurgitation occurs with pulmonary disease but is most often associated onset at the beginning of diastole, as soon as with heart failure. It is caused by the aortic valve closes, and produces an early gravity-dependent changes in pulmonary diastolic murmur. Myotonic dystrophy is capillary hydraulic pressure leading to alveolar associated with dilated cardiomyopathy and oedema. conducting system problems, which can lead 16 to atrioventricular block and ventricular arrhythmias. Long QT syndrome is an inherited 16.3. Answer: B. arrhythmia syndrome that is not usually The most common cause of a rapid, irregular associated with any structural cardiac rhythm in the elderly is atrial fibrillation. In abnormality. Mitral valve prolapse produces a patients with very frequent atrial or ventricular late systolic murmur. Wolff–Parkinson–White ectopic beats, the pulse is also very irregular syndrome is rarely associated with structural but a regular pattern can usually be perceived cardiac abnormalities (which are Ebstein’s within it. anomaly and rarely hypertrophic cardiomyopathy) and is not associated with 16.4. Answer: E. aortic incompetence. The internal jugular vein is in direct continuity with the right atrium, and there is no venous 16.7. Answer: D. valve between the two. The JVP therefore is a Clinical features of acute limb ischaemia include reflection of right atrial pressure, which pallor, pain, pulselessness, paraesthesia and becomes elevated in conditions where either ‘perishing-with-cold’ – the five ‘P’s. Deep there is increased resistance to right ventricular venous thrombosis would cause limb swelling, ejection (e.g. pulmonary hypertension due to venous engorgement, and a dusky blue chronic lung disease, or recurrent pulmonary discoloration, and this does not affect arterial embolism) or mechanical dysfunction of the flow. In cardiac failure, peripheral blood flow is right heart (e.g. right ventricular infarction, not sufficiently reduced to cause limb ischaemia right-sided valve disease). except in cardiogenic shock. In a patient with a history of atrial fibrillation, embolisation from 16.5. Answer: B. the left atrial appendage is the most likely The second heart sound, which occurs at the cause of limb ischaemia. Aspirin does not beginning of ventricular diastole, occurs when provide effective prophylaxis against this and the aortic and pulmonary valves close. When current guidelines recommend the use of either aortic or pulmonary artery diastolic warfarin or a direct oral anticoagulant such as pressure is high (e.g. in essential or pulmonary apixaban. 144 CARDIOLOGY 16.8. Answer: C. plasma troponin concentration takes time to Infective endocarditis is often diagnosed become detectable. The admission troponin relatively late in its clinical course. It may initially level may be normal if the patients attends present with non-specific symptoms that lead soon after the onset of symptoms. If the i i i i i i 6-hour troponin level is normal then acute patient with unexplained fever and a cardiac coronary syndrome is not likely to explain the murmur, especially if changing, should be patient’s chest pain and other causes should assessed for possible endocarditis, with then be considered. An elevated troponin level urinalysis, an ECG, echocardiogram, blood is suspicious of myocardial infarction cultures, and blood testing for white cell count but should be interpreted in the context of the and C-reactive protein concentration. In this clinical presentation. Some non-cardiac case the wide pulse pressure is suggestive of pathologies (e.g. sepsis, pulmonary embolism) aortic incompetence which, if severe, may are also commonly associated with minimal occur without a murmur. myocardial injury and therefore troponin release. 16.9. Answer: E. After myocardial infarction, haemodynamic 16.12. Answer: A. compromise associated with a new murmur Atrial fibrillation is the most common may be caused by either papillary muscle tachyarrhythmia encountered in older patients rupture, or rupture of the interventricular and is seen in approximately 2% of patients septum (acquired ventricular septal defect; aged over 70 years, and in some studies up to VSD). With acquired VSD the murmur often 10% of those aged over 80 years. Ventricular radiates to the right sternal border because of ectopic beats would not produce episodic left-to-right shunting across the interventricular symptoms of this type and sinus arrhythmia is septum, whereas the murmur of acute mitral a normal variant and would not cause any incompetence would be more likely to radiate symptoms. Supraventricular tachycardia to the axilla or the back. Acute left ventricular normally causes regular palpitation. free wall rupture is almost always fatal and would not cause a murmur. While pericarditis 16.13. Answer: D. may cause a sound that could be confused Basic life support describes the interventions for a murmur, serious haemodynamic that can be carried out with minimal equipment compromise is rare, as the associated in the event of a cardiac arrest. It does not pericardial effusion is usually small. Aortic include defibrillation or administration of incompetence is not a complication of intravenous drugs. It does include chest myocardial infarction. compression and mouth-to-mouth resuscitation, but the ABCDE mnemonic is a 16.10. Answer: B. helpful aide mémoire for these and the other Clinical signs of left ventricular failure are components of basic life support. tachycardia, a gallop rhythm with a third heart sound (which is the sound of abrupt left 16.14. Answer: E. ventricular filling due to high left atrial pressure), Pulseless electrical activity means that and bi-basal inspiratory fine crepitations at the there is an organised cardiac rhythm seen lung bases. A fourth heart sound occurs on the ECG, but no discernible cardiac output. during atrial systole because of increased left Defibrillation is not appropriate, as this is a ventricular stiffness in patients with left treatment for ventricular fibrillation. ventricular hypertrophy. A loud second heart Amiodarone can cause hypotension and is sound is usually caused by systemic or not an appropriate treatment. In current pulmonary hypertension. A quiet first heart resuscitation protocols, CPR should be carried sound may accompany mitral out for 2 minutes before the rhythm is regurgitation. reassessed. Reversible causes of PEA include hypothermia, hypoxia, hypovolaemia, hypo-/ 16.11. Answer: A. hyperkalaemia (the four ‘H’s), and Troponin testing is an important component in thrombosis (coronary or pulmonary), tension the assessment of patients with chest pain. pneumothorax, tamponade and toxins In patients with acute myocardial infarction, (the four ‘T’s).  CARDIOLOGY 16.15. Answer: E. 16.20. Answer: C. While peripheral oedema and ascites are First-line therapy for rate control in atrial signs of right-sided cardiac failure, they typically fibrillation consists of β-blockade (or, if take days or weeks to develop. Acute contraindicated, a rate-limiting calcium channel right ventricular failure is characterised by blocker such as verapamil can be used). In this hypotension, a compensatory sinus case, the β-blocker could be prescribed in tachycardia, elevation of the jugular venous place of enalapril, as it may provide quite pulse because of ineffective right ventricular effective blood pressure control, as well as ejection, and hepatomegaly can develop quite limiting the heart rate. None of the other agents quickly because of hepatic venous are appropriate for rate control in atrial congestion. fibrillation. Lidocaine is used to treat ventricular arrhythmias. Flecainide and amiodarone are 16.16. Answer: C. used for rhythm control (i.e. maintenance of Starling’s Law describes the relationship sinus rhythm) and not rate control, in atrial between cardiac filling (preload) and cardiac fibrillation. Adenosine is an ultra-short-acting output. Low preload causes inadequate atrioventricular (AV) node blocker and is not ventricular filling and low output. Moderate used to treat atrial fibrillation. preload causes optimal cardiac filling and cardiac output. Very high preload causes 16.21. Answer: C. ventricular stretch and reduces the efficiency of i contraction, resulting in reduced cardiac output. P waves conduct normally to the ventricles and Patients with decompensated cardiac failure are associated with a QRS complex. Some P have high preload pressure, and diuretics and waves do not conduct and there is no vasodilator medication can reduce this and preceding increase in the P–R interval before improve cardiac function. the blocked P wave. This reflects block in the His–Purkinje system where conduction is 16 16.17. Answer: A. i i Cardiac failure is associated with activation of second-degree AV block is characterised by the sympathetic nervous system and RAAS. progressive lengthening of the P–R interval The resulting production of noradrenaline block. This reflects block in the AV node itself, (norepinephrine) and angiotensin II cause where conduction is ‘decremental’, i.e. the AV peripheral vasoconstriction. BNP production node exhibits signs of ‘fatigue’ with each increases in cardiac failure in response to successive beat. ventricular stretch. 16.22. Answer: E. 16.18. Answer: B. Sinoatrial disease is characterised by Loop diuretics interfere with the countercurrent abnormalities of sinus rate, and atrial sodium exchanger in the loop of the nephron. arrhythmias such as atrial flutter, atrial This prevents water reabsorption and results in tachycardia and atrial fibrillation. Ventricular loss of sodium and water (natriuresis). arrhythmias are not commonly associated with this condition. 16.19. Answer: D. β-Blockers have several beneficial effects in 16.23. Answer: D. chronic cardiac failure – improvement of The CHA2DS2-VASc score is used to assess diastolic filling, reduction of myocardial stroke risk in patients with atrial fibrillation (and ischaemia, and prevention of ventricular atrial flutter). The mnemonic takes account of arrhythmias and atrial fibrillation. β-Blockers clinical risk factors for stroke (C, congestive reduce heart rate so should not be heart failure = 1 point; H, hypertension = 1 used if the patient is already bradycardic. In point; A2, age ≥ 75 years = 2 points; D, acute cardiac failure (e.g. acute left ventricular diabetes mellitus = 1 point; S2, previous failure or cardiogenic shock), in which left stroke or transient ischaemic attack = 2 points; ventricular systolic function is acutely V, vascular disease = 1 point; A, age 65–74 compromised, β-blockers should not be used years = 1 point; Sc, sex category female = 1 as they may further impair systolic point). In this case, the score is 5 points (2 function. points for age ≥ 75 years, 1 point each for 146 CARDIOLOGY female gender, diabetes and hypertension). comorbidities, age is not a barrier to This is associated with quite a high risk of implantation. ICDs are not indicated for patients stroke (approximately 5% annual risk if who have experienced ventricular arrhythmias untreated) and this patient should be due to reversible factors (e.g. drug misuse) or considered for oral anticoagulation. in the acute phase of myocardial infarction, as subsequent risk of similar arrhythmias is 16.24. Answer: B. generally low. Patients with sinoatrial disease or Antiplatelet drugs are no longer recommended AV nodal block without ventricular arrhythmia for stroke prevention in atrial fibrillation, are treated with a permanent pacemaker, not although they are effective at preventing stroke an ICD. due to carotid vascular disease. Amiodarone and β-blockers can help prevent atrial fibrillation 16.28. Answer: D. episodes but are not known to reduce stroke The only one of these conditions associated risk. Apixaban is an oral factor Xa inhibitor, with a significant intracardiac shunt is tetralogy which has been shown in large-scale clinical of Fallot. Central cyanosis occurs because of trials to be effective at preventing stroke in shunting of blood through a ventricular septal patients with atrial fibrillation and moderate-to- defect, and this is exacerbated by the high stroke risk. over-riding aorta (i.e. the aorta over-rides the defect, causing blood from the right ventricle to 16.25. Answer: E. be ejected directly into the aorta) and by This ECG shows a narrow, complex tachycardia muscular right ventricular outflow obstruction. with no obvious P waves. The P waves may be Cyanotic episodes may be precipitated by fever concealed in the QRS complex or ST segment. or by dehydration. In most cases the condition The term ‘supraventricular tachycardia’ is used is recognised and corrected in infancy. to describe this rhythm. The two most likely mechanisms are atrioventricular nodal 16.29. Answer: D. re-entrant tachycardia (AVNRT) or Eisenmenger’s syndrome occurs in patients atrioventricular re-entrant tachycardia (AVRT). with untreated intracardiac shunts such as atrial The key to terminating these tachycardias is to or ventricular septal defects. Initially shunting is cause transient block in the AV node and the from the left to the right side of the heart, and quickest and least invasive way of doing this is central cyanosis does not occur. The response by using vagal manoeuvres such as carotid to increased pulmonary blood flow is pulmonary sinus pressure or the Valsalva manoeuvre. vasoconstriction, which leads to permanent sclerotic changes in the pulmonary 16.26. Answer: C. microvasculature. This causes right heart Pacemakers are used to treat or prevent pressure to increase to the point it exceeds left bradycardia and the main indications are heart pressure. Shunt reversal and central (and symptomatic sinoatrial disease and AV nodal peripheral) cyanosis then occur. Breathlessness disease. Pacemakers are not effective at and fatigue are common symptoms. Patients preventing atrial fibrillation or supraventricular with Eisenmenger’s syndrome have markedly tachycardia. Sinus bradycardia in an athlete is a reduced life expectancy because of cardiac normal, physiological finding that requires no failure and cardiac arrhythmias. Patent foramen treatment. An implantable cardiac defibrillator ovale is not a cause of Eisenmenger’s (ICD), not a permanent pacemaker, is used to syndrome and it does not cause significant prevent sudden death due to ventricular intracardiac shunting. arrhythmias in vulnerable patients. 16.30. Answer: E. 16.27. Answer: E. Ventricular septal defect (VSD) causes a harsh ICDs are indicated for primary prevention in systolic murmur that may radiate to the right patients with previous myocardial infarction who side of the sternum. Small VSDs do not cause have chronically impaired left ventricular significant shunting but can produce a loud function. It is thought that the scar burden in murmur. Atrial septal defect might cause a these patients predisposes them to ventricular quiet systolic flow murmur. Persistent ductus arrhythmias, which, when they occur, are arteriosus causes a continuous murmur poorly tolerated. As long as there are no throughout systole and diastole. Patent  CARDIOLOGY foramen ovale produces no abnormal proteins such as troponins, tropomyosin, auscultatory findings. Mitral valve prolapsed myosin heavy chain, actin and actin-binding causes a late systolic murmur and is not proteins, among many, but cardiac sodium referred to as a ‘hole’ in the heart. channel gene mutations predispose to cardiac arrhythmias by causing long QT syndrome or 16.31. Answer: A. Brugada syndrome. Pericarditis is associated with friction between the epicardial surface of the heart and the 16.35. Answer: A. pericardial sac. This causes a scratchy Hypertrophic cardiomyopathy is characterised to-and-fro sound in time with the cardiac cycle, by left ventricular hypertrophy. This is often which is distinct from a murmur. It is associated asymmetric with the interventricular septum with pleuritic chest pain, which may be affected classically affected. There are other variants, by sitting forward or backward. Heart sounds such as apical hypertrophic cardiomyopathy. are either normal or, if there is a large pericardial effusion, diminished. It may occur in 16.36. Answer: D. the context of flu-like illness and a viral Cardiac transplantation is limited by the aetiology is common. Endocarditis is not availability of donor organs, the need for associated with pleuritic chest pain. Persistent life-long immunosuppressive therapy to prevent ductus arteriosus is a congenital (rather than rejection, and the risks of surgery and the acute) condition, which is associated with a drugs used afterwards. Therefore it is only continuous murmur. offered to patients with cardiac failure who remain symptomatic despite adherence with 16.32. Answer: D. optimal pharmacological therapy and, where Aspirin, through its anti-inflammatory effects, is appropriate, cardiac resynchronisation therapy. a very effective symptomatic treatment for pericarditis. Non-steroidal anti-inflammatory 16.37. Answer: E. 16 drugs such as diclofenac can also be used Hypertrophic cardiomyopathy is associated with orally. Steroids are rarely required. Amiodarone disorganisation and fibrosis of left ventricular is an anti-arrhythmic drug and has no role in myocardial tissue. This can predispose patients the management of acute pericarditis. to sudden ventricular arrhythmias, and these may occur without warning during intense 16.33. Answer: A. exercise. The risk is highest in patients with Dilated cardiomyopathy is characterised by gross hypertrophy or left ventricular outflow dilatation of the atria and ventricles, and tract obstruction. Some genetic variants are thinning of ventricular walls. Hypertrophic also associated with high risk, such as troponin cardiomyopathy causes disproportionate T mutations. Right ventricular failure and thickening of myocardium, particularly the pulmonary embolism are not common in interventricular septum. Myocardial infiltration patients with hypertrophic cardiomyopathy. (e.g. with amyloid protein) can cause restrictive Atrial fibrillation occurs and may cause cardiomyopathy, which does not cause cardiac symptoms but is rarely life-threatening. dilatation but does restrict myocardial contraction and relaxation. 16.38. Answer: B. Loop diuretics have no effect on mortality in 16.34. Answer: B. patients with cardiac failure. Rate-limiting Cigarette smoking is a leading cause of i i i cardiovascular disease but its main influence is verapamil are usually avoided, as they have a on the genesis of atherosclerosis and coronary negative inotropic effect, which may aggravate artery disease. Likewise, obesity is associated cardiac failure. Aspirin and percutaneous with risk of hypertension and type 2 diabetes coronary intervention are treatments for mellitus, but is not a risk factor for coronary artery disease, not cardiomyopathy. cardiomyopathy. Hypercholesterolaemia may have dietary and genetic components and is a 16.39. Answer: A. risk factor for coronary artery disease, not Takotsubo (stress) cardiomyopathy occurs cardiomyopathy. Dilated cardiomyopathy can most often in females and is associated with be caused by genetic defects of sarcomeric emotional stress. It can occur due to 148 CARDIOLOGY bereavement, acute non-cardiac illness, natural relieve symptoms and to obtain fluid for disasters and other major life events. It is laboratory analysis. Patients with pericardial characterised by chest pain and ECG changes effusion are very dependent on high preload that mimic myocardial infarction. Troponin pressure to maintain cardiac output, so elevation is common but coronary angiography diuretics may cause significant hypotension. does not show occlusive coronary artery disease Large effusions may occur because of or intracoronary thrombus. Echocardiography malignancy, usually metastatic disease from shows a characteristic left ventricular lung or breast cancer. appearance of apical dilatation, giving the appearance of an octopus trap or takotsubo! 16.44. Answer: B. ‘Saddle’ ST segment elevation is a common 16.40. Answer: A. feature of acute pericarditis, but it can be Alcohol has many negative effects on health. confused with an ST segment elevation These include liver disease, pancreatitis, myocardial infarction, Brugada syndrome, and hypertension and cognitive dysfunction. It also a normal variant in some ethnic groups such as causes many behavioural and social problems, those of African or Caribbean descent. In particularly if alcohol dependency occurs. contrast, PR interval depression is very specific Cardiac effects include atrial fibrillation and to pericarditis and, when seen, is usually dilated cardiomyopathy, both of which diagnostic. may be reversible if the patient abstains early enough. 16.45. Answer: D. Sinus tachycardia is the most common ECG 16.41. Answer: D. abnormality in pulmonary embolism, although Atrial myxoma is the most common cardiac atrial fibrillation may also occur. The next tumour and 75% or more occur in the left commonest ECG change is anterior T-wave atrium. Large tumours may partially obstruct inversion due to right ventricular wall stress. the mitral valve, affecting cardiac output and i causing a tumour ‘plop’ on auscultation. and T-wave inversion in lead III) pattern is Tumours are benign but can be associated commonly absent but, when present, is more with cerebral and peripheral embolism (which is specific to massive pulmonary embolism. how they often first present), so surgery is usually indicated to prevent this. 16.46. Answer: D. Although elevation of the JVP and peripheral 16.42. Answer: E. oedema often occur with chronic pericardial Chronic pericardial constriction is a late effusion, they are not specific signs of cardiac complication of tuberculous and viral tamponade. Here, pulsus paradoxus and pericarditis and is caused by pericardial fibrosis, Kussmaul’s sign (the JVP falling on inspiration) contraction and adhesion to the epicardium. are specific signs. Pulsus paradoxus is an It can also complicate chronic inflammatory exaggeration of physiological variation in blood disorders such as rheumatoid disease. Acute pressure caused by compression of the heart myocardial infarction can lead to acute in the pericardial sac, and is characterised by a post-infarct pericarditis, but this almost never large fall in blood pressure during inspiration. leads to pericardial constriction. 16.47. Answer: C. 16.43. Answer: A. All of the agents listed except furosemide have Large pericardial effusions are normally not been shown to improve survival in patients with associated with a pericardial rub as the heart failure due to left ventricular systolic pericardium and epicardium are well separated dysfunction. Loop diuretics such as furosemide by pericardial fluid and friction does not occur. are important for symptom control, but so far, The ECG may show small complexes but is not no large-scale randomised trial has shown a sensitive test, and an echocardiogram is survival benefit. required to make the diagnosis. The chest X-ray may show a spherical or globular 16.48. Answer: C. cardiac silhouette. In symptomatic patients, P2Y12 receptor antagonists inhibit adenosine percutaneous pericardial drainage is used to diphosphate (ADP)-dependent platelet  CARDIOLOGY activation and all of the agents listed except by diastolic dysfunction – the inability of the left dipyridamole act via this receptor. Dipyridamole ventricle to fill properly in diastole. is a phosphodiesterase inhibitor, which blocks the response to ADP by inhibiting breakdown 16.52. Answer: D. of cyclic adenosine monophosphate (cAMP) Both the sympathetic nervous system and the and inhibits the re-uptake of adenosine into RAAS systems are activated in heart failure. platelets. Vasopressin may also be released from the posterior pituitary in response to reduced 16.49. Answer: E. cardiac output. Thyroid hormone levels are Smoking is by far the strongest modifiable risk generally unaffected in cardiac failure but factor for coronary artery disease. Obesity is profound hypo- or hyperthyroidism can cause associated with hypertension, type 2 diabetes heart failure. and unfavourable lipid profile, and is thus associated with risk of myocardial infarction. 16.53. Answer: E. High levels of dietary saturated fat (e.g. from Troponin I is a structural myocardial protein red meat and processed meat products) are i i also known to be associated with increased other markers listed, it is released into the cardiovascular risk. blood stream after acute myocardial infarction from injured myocardial tissue. 16.50. Answer: E. Both percutaneous coronary intervention and 16.54. Answer: C. fibrinolytic drug therapy are treatment If the patient has occluded his stent, then modalities for acute ST elevation myocardial the ECG will show an acute inferior ST infarction. Both treatments aim to re-open the segment elevation myocardial infarction. culprit coronary vessel to restore perfusion to Electrocardiographic features of acute inferior the infarct territory. In randomised studies, myocardial infarction include ST segment 16 administration of tPA or other fibronolytic drugs elevation in the inferior leads (II, III and aVF) and had a strongly time-dependent beneficial effect. sometimes atrioventricular block. If administered more than 8–10 hours after the onset of symptoms, risk of treatment begins to 16.55. Answer: A. outweigh benefit. As fibrinolytic drugs take Sudden, severe pulmonary oedema after time to work, and may not completely restore myocardial infarction may be a sign of a flow in the culprit vessel, they are best mechanical complication. Acute papillary administered early. Percutaneous coronary muscle rupture causes sudden and very severe intervention and the other therapies described mitral regurgitation, which, in turn, is do not have such a time-dependent effect on complicated by pulmonary oedema. Acute outcome. When primary percutaneous coronary pericarditis causes sharp chest pain but does intervention cannot be provided within 2 hours, not cause pulmonary oedema. Free wall rupture fibrinolytic therapy should be administered usually causes pulseless electrical activity (PEA) immediately. cardiac arrest and is almost always fatal. Atrial septal defect is not a complication of 16.51. Answer: E. myocardial infarction. Left ventricular mural Dilated cardiomyopathy, myocarditis and thrombus is usually asymptomatic, and is myocardial infarction all reduce left ventricular detected on echocardiography. It can lead to systolic function and are associated with low stroke and peripheral embolism. left ventricular ejection fraction (LVEF), a measure of the percentage of left ventricular 16.56. Answer: E. blood ejected in systole. Aortic stenosis is Ventricular fibrillation is an early complication associated with either normal LVEF, or if of acute myocardial infarction and is the severe, sometimes low LVEF. Restrictive leading preventable cause of death. Early cardiomyopathy is associated with myocardial recognition of myocardial infarction is therefore infiltration and sometimes reduction in left important. Sudden death rates may be reduced i i i i by education of the public about symptoms function. LVEF is high but stroke volume low of myocardial infarction and the need to i i i i seek immediate medical help, and by the 150 CARDIOLOGY now-ubiquitous placement of external can cause limb ischaemia because of its defibrillators in emergency ambulances. association with stroke and peripheral Community first responder programmes and embolism. Diabetes mellitus is associated with public access defibrillation are other strategies atherosclerotic and microvascular disease that allow a more rapid response to myocardial and is strongly linked with limb ischaemia; infarction and cardiac arrest in rural areas. however, it would be unusual in a normal-weight individual of this age without 16.57. Answer: A. symptoms. Diabetes mellitus has been shown in large cohort studies to be protective against the risk 16.61. Answer: C. of development of abdominal aortic aneurysm, While control of blood pressure is important in and where aneurysm is present, the rate of type A aortic dissection, through use of enlargement is slower than in non-diabetics. β-blockers or other antihypertensive agents, it The reason for this negative association is is early surgery that has the greatest effect on unclear. mortality. Type A aortic dissection involves the ascending aorta and patients may die because 16.58. Answer: A. of cardiac tamponade, aortic rupture, or Acute limb ischaemia leads to pallor, pain, dissection into downstream arteries resulting in pulselessness, paraesthesia and ischaemia of limbs or organs. The most ‘perishing-with-cold’ – the five ‘P’s. Chronic effective way of preventing this is to repair the limb ischaemia is associated with hair loss in entry point of the dissection in the ascending the affected limb. Capillary refill time is a aorta. Anticoagulation is contraindicated in measure of peripheral perfusion and is tested acute aortic dissection as it may cause fatal i i bleeding. until it blanches, then assessing the time taken for colour to fully return. A capillary refill time of 16.62. Answer: D. < 2 seconds is a sign of good peripheral Hypertension, because of its population perfusion and if > i i prevalence, is the leading cause of aortic reduced peripheral perfusion. dissection; however, this would have been picked up on antenatal checks in this case. 16.59. Answer: C. Marfan’s syndrome (usually associated with tall β-Blockers and ACE inhibitors help reduce stature) and coarctation of the aorta are arterial wall stress and, through their role in relatively uncommon conditions, but both have controlling hypertension, may help reduce risk a strong association with aortic dissection. of aortic aneurysm expansion and rupture. Intramural haematoma refers to spontaneous Statins reduce the rate of progression of bleeding into the aortic wall and may be the atherosclerosis and may help reduce risk of precursor to aortic dissection. Pregnancy- rupture through cholesterol-dependent and associated dissection is rare, but when it cholesterol-independent effects. However, of all occurs it is usually in the third trimester or interventions, smoking cessation has the postpartum period, and is more likely to occur greatest effect in reducing the risk of aneurysm in patients with predisposing conditions such rupture. as Marfan’s syndrome. 16.60. Answer: C. 16.63. Answer: C. Atherosclerotic peripheral vascular disease is Primary percutaneous coronary intervention the most common cause of limb ischaemia. (PPCI) is more effective at reperfusing the Buerger’s disease is a form of obliterative infarct-related territory than fibrinolysis with ii i i i streptokinase or tPA. Fibrinolytic drugs may not vessels, strongly associated with cigarette reach the site of vessel occlusion if there is no smoking. It causes limb ischaemia and flow, and will do nothing to treat the culprit gangrene, and presents at a relatively young occlusive atherosclerotic lesion. PPCI usually age. Raynaud’s disease is a vasospastic completely restores blood flow by fragmenting condition associated with some connective the clot and by opening up the site of stenosis. tissue disorders. It can cause digital ischaemia It is associated with lower mortality and lower and in some cases infarction. Atrial fibrillation rates of subsequent angina and re-infarction.  CARDIOLOGY Coronary artery bypass surgery is not used to 16.69. Answer: C. treat acute myocardial infarction but is an Mitral stenosis is characterised by the presence effective treatment for some patients with of a tapping apex beat, reflecting a palpable chronic coronary artery disease. opening snap, accompanied by a low-pitched mid-diastolic murmur. If the patient is in sinus 16.64. Answer: A. rhythm, pre-systolic accentuation of the There is a strong association between age and murmur may occur because of atrial risk of death after myocardial infarction. contraction. A loud second heart sound may In-hospital mortality is three times greater in be heard due to secondary pulmonary individuals aged over 80 years than it is in hypertension, which often accompanies mitral those aged 60–65 years. While risk of stenosis. myocardial infarction is much higher in smokers than in non-smokers to start with, the risk of 16.70. Answer: A. death in smokers after myocardial infarction is A thrill is indicative of aortic stenosis or lower than in non-smokers, probably because hypertrophic obstructive cardiomyopathy, both their main risk factor is modifiable. ECG of which are not associated with a parasternal changes and troponin concentration are not heave. A parasternal heave occurs because of good predictors of mortality risk. Cardiac arrest right ventricular hypertrophy and does not within 24 hours of myocardial infarction is an cause a thrill. Conditions which lead to effect of acute ischaemia and does not predict pulmonary hypertension (e.g. mitral stenosis, risk of sudden death after discharge from chronic lung disease and atrial septal defect) hospital. may therefore cause right ventricular hypertrophy and a parasternal heave. 16.65. Answer: D. There are many uncommon endocrine causes 16.71. Answer: C. of hypertension, including those listed, but renal Aortic regurgitation is associated with a 16 disease is the most common cause. large-volume, collapsing pulse and an early diastolic murmur associated with a systolic 16.66. Answer: D. ‘flow’ murmur. In severe aortic regurgitation, All other options given apart from D describe the pulse pressure may be so large as to cause recognised causes of secondary hypertension. prominent neck pulsation. A slow rising pulse, Antihypertensive drug therapy, along with crescendo–decrescendo murmur, quiet second lifestyle changes, effectively controls blood heart sound and palpable thrill in the aortic area pressure in most patients with hypertension. are signs of aortic stenosis. The most common cause of poor blood pressure control is therefore poor adherence 16.72. Answer: E. with antihypertensive therapy. This may be Viridans streptococci are the most common because of side-effects, and also because of cause of endocarditis on a native heart valve. the asymptomatic nature of the condition. Staphylococcus aureus is the most common organism to infect prosthetic valves. 16.67. Answer: D. The revised Jones criteria are used to diagnose 16.73. Answer: A. rheumatic fever. The condition is diagnosed Cutaneous signs of endocarditis (options B, D if two major criteria are met, or one major and E) are not seen in most patients with the and two minor criteria are met. Carditis, condition, but when present, are highly subcutaneous nodules, erythema marginatum diagnostic of it. Roth’s spots (seen on and chorea are all major criteria, whereas fundoscopy) are also relatively uncommon. elevation of C-reactive protein (or erythrocyte Haematuria (often microscopic) is a common sedimentation rate) is a minor criterion. manifestation of endocarditis. 16.68. Answer: A. 16.74. Answer: B. Aspirin is the drug of choice in rheumatic fever Viridans streptococci are usually very sensitive and is used in high doses compared with those i ii i used in common analgesia. Glucocorticoids are synergistically with gentamicin. Bactericidal not used in this condition. blood concentrations can only be achieved with 152 CARDIOLOGY frequent intravenous dosing. Ampicillin is not as of myocardial fibrosis. In addition to assessing effective, and flucloxacillin and vancomycin are scar burden and distribution after myocardial principally used to treat staphylococcal infarction, it is also helpful in the diagnosis of infections. and risk stratification in cardiomyopathies, because of the association between myocardial 16.75. Answer: A. fibrosis, these conditions, and risk of ventricular Hypertrophic cardiomyopathy is often familial, arrhythmias. It is also useful to help guide the and the most common mode of inheritance is likelihood of success from coronary artery autosomal dominant. bypass graft surgery. 16.76. Answer: A. 16.81. Answer: B. Mutations in myosin heavy chain, troponin and The main components in the management of myosin-binding protein most often lead to acute pulmonary oedema are bed rest, oxygen hypertrophic cardiomyopathy. Titan mutations therapy, intravenous nitrates and intravenous (and some myosin-binding protein mutations) diuretics. Non-invasive continuous positive may cause dilated cardiomyopathy. It is airway pressure (CPAP) ventilation is helpful in mutations in fibrillin, a glycoprotein critical to resistant cases. Dobutamine is an inotrope that production of elastic tissue, that most often increases cardiac work; it is sometimes used in leads to Marfan’s syndrome. the management of cardiogenic shock, but is not appropriate in a patient with high blood 16.77. Answer: B. pressure and cardiac failure. Atrial myxoma is the most common cardiac tumour. It is a benign tumour that usually 16.82. Answer: B. occurs in the left atrium and is associated with Endocrine causes of dilated cardiomyopathy, increased risk of stroke and peripheral and alcohol-related cardiomyopathy, are often embolism. reversible as long as the underlying problem is treated early enough. Anthracycline 16.78. Answer: C. chemotherapy can cause acute or late-onset Transthoracic echocardiography is a form of dilated cardiomyopathy that responds only in a ultrasound imaging that has limitations. It is limited manner to β-blockers and ACE inhibitors good for assessing heart valve and myocardial and which may cause permanent cardiac function but has limited value in characterising dysfunction. tissues (e.g. for fibrosis). The left atrial appendage is the most common site for 16.83. Answer: C. thrombus formation in atrial fibrillation and this Non-ST segment myocardial infarction is structure is not visible during transthoracic normally initially managed with dual antiplatelet echocardiography. The electrocardiogram, not therapy (e.g. aspirin and ticagrelor), and an echocardiogram, is used to assess cardiac antithrombotic agent (e.g. fondaparinux or arrhythmias. Whilst poor left ventricular function enoxaparin). β-Blockade is often used as is associated with a poor future prognosis, in prophylaxis against angina and arrhythmias. isolation, echocardiography gives limited Intravenous tPA is a treatment for acute ST information about prognosis. elevation myocardial infarction and has not been shown to improve outcome in patients 16.79. Answer: B. with non-ST segment elevation myocardial The decision between percutaneous coronary i