Cardiology - 1 File Download



|Cardiology |

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|[MRCP 1 |

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|[Pick the date28/03/11] |

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|Faraz |

Cardiology - Pastest

1. A 46-year-old Asian man with a past history of coronary artery bypass grafting presents with breathlessness. The jugular venous pressure (JVP) shows prominent x and y descents. The most likely cause is?

|[pic] |Constrictive pericarditis |[pic]Your answer |

|[pic] |Dilated cardiomyopathy | |

|[pic] |Pericardial effusion | |

|[pic] |Restrictive cardiomyopathy | |

|[pic] |Severe mitral regurgitation | |

A prominent x descent in the jugular venous pressure (JVP) may occur in constrictive pericarditis or pericardial effusion. The y descent is lost in tamponade but prominent in constrictive pericarditis. Constrictive pericarditis was classically caused by tuberculosis, but today is more commonly associated with cardiac surgery, renal failure or following infective pericarditis. Restrictive cardiomyopathy may produce clinical features similar to constriction, but is less common.

2. A 52-year-old man undergoes Bruce-protocol exercise testing 6 weeks following an uncomplicated inferior myocardial infarction. He is currently on aspirin 75 mg od, simvastatin 40 mg od, lisinopril 20 mg od and atenolol 25 mg od. Resting heart rate is 72 bpm and blood pressure is 130/70 mmHg. He achieves 4 minutes 15 seconds, stopping secondary to chest pain and associated ST-segment depression in the inferolateral leads. What would be the next stage in his management?

|[pic] |Add diltiazem and review in clinic | |

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|[pic] |Arrange an echocardiogram | |

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|[pic] |Increase atenolol 50 mg od and repeat the exercise test | |

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|[pic] |Refer for coronary angiography |[pic]Your answer |

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|[pic] |Refer for a myocardial perfusion scan | |

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The purpose of the exercise test postmyocardial infarction is twofold: risk stratification and patient self-confidence. Patients who are unable to perform two stages of the Bruce protocol (< 6 minutes) are at higher risk of adverse cardiovascular events. This youngish man has an early positive exercise test, as exemplified by symptoms and associated ECG changes. He should be referred for coronary angiography to accurately determine whether he has prognostic disease warranting coronary artery bypass grafting (left main stem disease, proximal three-vessel disease and proximal two-vessel disease including the left anterior descending artery). Percutaneous intervention can also be considered if he has ongoing symptoms (likely in view of his symptoms on exercise testing). Increasing his atenolol dose would be a sensible amendment to his current medical therapy.

3. A 70-year-old woman is admitted to hospital with a swollen left leg 4 weeks after undergoing an elective total hip replacement. An above-knee DVT is diagnosed by ultrasound. She is in sinus rhythm at 60 bpm and her blood pressure is 160/80 mmHg. She is commenced on the appropriate dose of low molecular weight heparin and warfarin loading. The following day she becomes acutely short of breath. Examination reveals a resting tachycardia (110 bpm) with blood pressure of 100/60 mmHg. Her JVP is elevated at 7 cm above the sternal notch. Arterial blood gas measurement reveals her to be hypoxaemic with a pa(O2 ) of 7 mmHg.

What would be the first-line therapy after administering high-flo oxygen?

|[pic] |Aspirin | |

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|[pic] |Intravenous heparin | |

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|[pic] |Surgical embolectomy | |

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|[pic] |Thrombolysis with reteplase |[pic]Your answer |

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|[pic] |Vena caval filter | |

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This patient has clinical features of a massive pulmonary embolus. This results from significant obstruction of the pulmonary arteries causing haemodynamic compromise – namely shock or systemic hypotension (systolic blood pressure < 90 mmHg or a drop of > 40 mmHg for > 15 minutes). The initial treatment of choice is thrombolysis using a recognised protocol. Whilst she is only 4 weeks out from her hip replacement, the benefits of thrombolysis would outweigh the risks in this case.  Inotropic support and the judicious use of fluids may also be required in the interim. Subsequent intravenous unfractionated heparin should then be commenced.

4. A 67-year-old diabetic is admitted with chest pain radiating to his left shoulder and jaw. He is a moderate smoker. Serum cholesterol and LDL levels are raised and the ECG shows ST depression in the inferolateral leads.

What would be your line of management?

|[pic] |Transfer the following day for  coronary angiography followed by angioplasty | |

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|[pic] |Thrombolysis with streptokinase, clopidogrel and aspirin | |

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|[pic] |Oral aspirin, clopidogrel and atenolol | |

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|[pic] |Glyceryl trinitrate, heparin, aspirin, clopidogrel and atorvastatin |[pic]Your answer |

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|[pic] |Tissue-type plasminogen activator, aspirin, warfarin and simvastatin | |

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Nitrates relieve ischaemic pain. Low molecular weight heparin should be given as it has a longer duration of action and doesn’t require monitoring. Atorvastatin is more effective than simvastatin at reducing cholesterol levels. Clopidogrel prevents myocardial infarction and death in patients with acute coronary syndrome if given in addition to aspirin. Although this combination increases the risk of bleeding, the reduction in events outweighs any increased bleeding events.

5. A 60-year-old man with unstable angina on long-term digoxin was being monitored on the ward with telemetry when the monitor displayed a tachycardia of 180 bpm. The printout showed discrete P waves before each QRS complex and there was an acceleration in the rate after initiation of the arrhythmia. The QRS width was 0.12 s. Which of the following is the most likely arrhythmia?

|[pic] |Automatic supraventricular tachyarrhythmias |[pic]Your answer |

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|[pic] |AV nodal re-entrant tachycardia | |

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|[pic] |Bypass tract-mediated macroentrant tachycardia | |

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|[pic] |Intra-atrial re-entry | |

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|[pic] |Ventricular tachycardia | |

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Automatic supraventricular arrhythmias characteristically show a warm-up phenomenon: that is, the rate accelerates after its initiation. Options B, C and D are all types of re-entrant supraventricular arrhythmias. In options B and C, P waves are not seen on the ECG. In contrast, there are discrete P waves in intra-atrial re-entry but there is no warm-up phenomenon. The normal QRS width rules out a ventricular tachycardia.

6. A 75-year-old man with congestive cardiac failure presents with atrial fibrillation. He is haemodynamically stable with a ventricular rate of 72. Which drug option would be most beneficial for this patient?

|[pic] |Aspirin | |

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|[pic] |Digoxin | |

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|[pic] |Frusemide | |

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|[pic] |Lidocaine | |

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|[pic] |Warfarin |[pic]Your answer |

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Patients with atrial fibrillation who are stable pose an intermediate risk. The initial treatment in this case is anticoagulation with warfarin. This is indicated in valvular heart disease and in the elderly. Digoxin is effective in controlling the heart rate at rest.

7. A 50-year-old man with long-standing hypertension presents acutely with severe chest pain radiating through to his back. He looks unwell, with a resting tachycardia (110 bpm) and blood pressure of 150/96 mmHg. There are no murmurs and neurological examination is normal. An urgent CT scan of his chest confirms type-A aortic dissection. The local cardiothoracic centre is contacted and urgent transfer arranged. He has received appropriate opiate analgesia. What additional drug treatment should be instigated as part of his immediate treatment plan?

|[pic] |Intravenous GTN | |

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|[pic] |Intravenous labetalol |[pic]Your answer |

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|[pic] |Intravenous nitroprusside | |

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|[pic] |Oral amlodipine | |

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|[pic] |Oral enalapril | |

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Type-A dissection involves the ascending aorta, and treatment with urgent surgical intervention is recommended unless severe co-morbidity would preclude the patient from surgery. Immediate management includes the liberal use of opiates for complete pain relief, thereby decreasing the sympathetic drive. Meticulous blood pressure control is vital while awaiting surgery/transfer, in an attempt to reduce the chances of extension or rupture. Short-acting intravenous β-blockers (eg labetalol) are the first choice drugs as they reduce both blood pressure and force of ejection. A short half-life is important since haemodynamics can change rapidly. If β-blockers are contraindicated then sodium nitroprusside or calcium-channel blockers may be appropriate alternatives.

8. A 21-year-old woman has a history of palpitations and light-headedness. The electrocardiogram (ECG) shows a short PR interval and inferior Q waves. Her symptoms improve with atenolol 25 mg/day, but she has had two short episodes of similar symptoms in the previous 24 hours. What is the long-term management of choice?

|[pic] |Anticoagulation | |

|[pic] |Oral amiodarone | |

|[pic] |Oral digoxin | |

|[pic] |Increase the dose of atenolol | |

|[pic] |Radiofrequency ablation |[pic]Your answer |

The short PR interval without delta wave suggests Long–Ganong–Levine (LGL) syndrome rather than Wolf–Parkinson–White (WPW) syndrome. It is likely that the patient is suffering from short periods of supraventricular tachycardia, which result in her palpitations and light-headedness. The management of WPW and LGL syndrome is similar, radiofrequency ablation is recommended for these patients. Digoxin is not recommended as it may result in an increased ventricular rate and worsen any circulatory compromise during attacks of tachycardia. Long-term oral amiodarone therapy is not recommended in view of the age of this patient. Atenolol may be useful to manage ventricular rate during periods of tachycardia, but again is a sub-optimal choice for this patient in the long term.

9. A 41-year-old man with a family history of sudden death presents to casualty with a second episode of collapse. On this occasion he is referred to the Cardiology Department for review. Echocardiography reveals asymmetrical septal hypertrophy, abnormal systolic motion of the anterior mitral valve leaflet and narrowing of the left ventricular outflow tract. The 24-h electrocardiogram (ECG) monitoring as an outpatient reveals several periods of non-sustained ventricular tachycardia.

 

Which of the following would be most appropriate for the management of his arrhythmia?

|[pic] |Oral flecainide 100 mg daily | |

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|[pic] |Oral amiodarone 200 mg tds | |

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|[pic] |Oral amiodarone 200 mg daily | |

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|[pic] |Implantable cardioverter defibrillator |[pic]Your answer |

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|[pic] |Phenytoin 100 mg po daily | |

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Given this clinical history, this patient has a diagnosis of hypertrophic obstructive cardiomyopathy. He has non-sustained ventricular tachycardias and is at significant risk of sudden death. While myomectomy will impact on symptoms, it won’t affect the risk of arrhythmia. Management in the past would have been medical therapy with amiodarone, but recent studies have demonstrated superior efficacy for implantable cardioverter defibrillators (ICDs). Given that long-term use of amiodarone is associated with significant morbidity, ICDs are taking over as management of choice.

10. A 65-year-old man presents to casualty with severe chest pain. ECG shows anterior ST-segment elevation and he receives prompt thrombolysis with reteplase with good resolution of changes. He is commenced on aspirin, a β-blocker, an ACE inhibitor and a statin. His initial progress is complicated by further pain, worse with inspiration and movement and relieved by non-steroidal drugs. You are called to see him on day 5 postinfarct when he complains of shortness of breath on walking to the bathroom. He looks unwell with a cool periphery and resting tachycardia. Blood pressure is reduced at 90/50 mmHg. Jugular venous pressure is elevated to around 8 cm and rises with inspiration. His ECG shows preserved anterior R waves and anterolateral T-wave inversion together with sinus tachycardia. Chest X-ray shows an increase in the cardiothoracic ratio but clear lung fields. What is the most likely complication to have developed to account for this deterioration?

|[pic] |Cardiogenic shock | |

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|[pic] |Mitral regurgitation | |

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|[pic] |Pericardial tamponade |[pic]Your answer |

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|[pic] |Pulmonary embolism | |

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|[pic] |Ventricular septal defect | |

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Devastating complications still do occur following acute myocardial infarction. Cardiogenic shock tends to occur early following a large infarct (or in the presence of already impaired left ventricular function), typically in the first 24–48 hours. The development of acute mitral regurgitation or VSD is associated with severe pulmonary oedema. While they would give rise to an elevation of jugular venous pressure, Kussmaul’s sign would not be present (increase in JVP with inspiration). Although pericarditis is common following an MI, and in particular anterior MI, tamponade occurs relatively infrequently. Chest X-ray shows a large heart with normal pulmonary vasculature. Echocardiography is vital to assist in the management of such a patient and permits easy differentiation of the possible causes of haemodynamic collapse.

11. A 65-year-old man with angina pectoris undergoes serum lipid testing. Which of the following abnormalities is most likely to be found?

|[pic] |Increased triglyceride levels | |

|[pic] |Increased low-density lipoprotein cholesterol levels |[pic]Your answer |

|[pic] |Increased high-density lipoprotein cholesterol levels | |

|[pic] |Increased chylomicrons | |

|[pic] |Increased intermediate-density lipoprotein cholesterol levels | |

|LDL particles are the main carriers of cholesterol. These particles can deposit lipid into the walls of the peripheral |

|vasculature. There is a strong association between both total- and LDL-cholesterol concentration and coronary heart risk. There is|

|a relatively weak independent link between raised concentrations of (triglyceride-rich) VLDL (very low-density lipoprotein) |

|particles and cardiovascular risk. Very highly raised triglyceride levels (> 6 mmol/l) cause a greatly increased risk of acute |

|pancreatitis and retinal vein thrombosis. |

|Higher HDL concentrations protect against cardiovascular disease. HDL also has effects on the function of platelets and of the |

|haemostatic cascade. These properties may favourably influence thrombogenesis. Excess chylomicrons do not confer an excess |

|cardiovascular risk but do raise the total plasma triglyceride concentration. |

12. A patient presents with congestive heart failure. Which drug may be effective in reducing mortality?

|[pic] |Enalapril |[pic]Your answer |

|[pic] |Aspirin | |

|[pic] |Digoxin | |

|[pic] |Frusemide | |

|[pic] |Lidocaine | |

Standard drugs like digitalis and diuretics have not been shown to improve survival rates. A number of studies have conclusively demonstrated that reduction in left ventricular afterload prolongs survival rates in congestive heart failure. Vasodilators such as angiotensin-converting enzyme (ACE) inhibitors are thus effective by inhibiting the formation of angiotensin II and thus affecting coronary artery tone and arterial wall hyperplasia. Lidocaine and other antiarrhythmic agents are useful only when there is arrhythmia associated with heart failure. Aspirin is indicated only in cases of coronary occlusion or myocardial infarction.

13. An elderly, normotensive man with poor left ventricular function presents with a broad-complex tachycardia. Which of the following drugs would be the first choice in treatment?

|[pic] |Sotalol | |

|[pic] |Amiodarone |[pic]Your answer |

|[pic] |Verapamil | |

|[pic] |Lidocaine | |

|[pic] |Flecainide | |

The patient has ventricular tachycardia. Verapamil may precipitate a circulatory collapse in VT and is therefore contraindicated. In the presence of poor left ventricular function, lidocaine and ß-blockers should not be used. Flecainide may cause ventricular fibrillation in stable tachycardias. Amiodarone would therefore be the first choice.

14. A 62-year-old patient presents with atrial fibrillation of unknown duration.

Which drug may slow his ventricular rate but is unlikely to result in cardioversion?

|[pic] |Adenosine | |

|[pic] |Amlodipine | |

|[pic] |Digoxin |[pic]Your answer |

|[pic] |Flecanide | |

|[pic] |Verapamil | |

Digoxin has inotropic actions based on inhibition of cardiac Na+/K+ ATPase; the antiarrhythmic activity appears to be mediated predominantly through vagal stimulation. Digoxin is used to slow ventricular rate in atrial fibrillation. Adenosine will reveal underlying atrial tachycardia but is unlikely to result in cardioversion versus flecanide.

15. A 75-year-old man with isolated systolic hypertension, who also has urinary incontinence, gout and asthma, attends outpatients with a blood pressure reading of 190/86 mmHg. Which of the following drugs would you initiate for this patient?

|[pic] |Amlodipine |[pic]Your answer |

|[pic] |Atenolol | |

|[pic] |Bendrofluazide | |

|[pic] |Doxazosin | |

|[pic] |Valsartan | |

Amlodipine, a dihydropyridine calcium-channel blocker, is the drug of choice for the treatment of isolated systolic hypertension in the elderly, especially if thiazides are contraindicated in a patient, as in this man. Doxazosin is contraindicated in patients with urinary incontinence, and, similarly, asthma negates the use of ß-blockers.

16. ou are called urgently to review a 54-year-old man who has developed acute onset pulmonary oedema some 36 h after his myocardial infarction. On arrival you note that his blood pressure is 95/50 mmHg with a pulse of 100/min regular and a pan-systolic murmur is noted. There are crackles on auscultation of the chest consistent with heart failure. Which of the following represents the next investigation of choice in this man?

|[pic] |Troponin I | |

|[pic] |Troponin T | |

|[pic] |Urgent chest X-ray | |

|[pic] |Referral for angiography | |

|[pic] |Urgent echocardiogram |[pic]Your answer |

The timing of this man’s deterioration coupled with a murmur of mitral regurgitation and acute pulmonary oedema suggests the onset of papillary muscle dysfunction or even rupture. Echocardiogram is the investigation of choice to demonstrate the mitral regurgitation. Management involves the use of vasodilators such as sodium nitroprusside and the use of angiotensin-converting enzyme (ACE) inhibition if tolerated. Inotropic support with drugs such as dopamine or dobutamine may also be required. The case should be discussed with cardiothoracic surgical colleagues to assess suitability for surgical repair, although this should be postponed until after haemodynamic stabilisation if possible due to the high risks of peri-infarct surgical intervention.

17. A 63-year-old man, admitted for chest pain and raised troponin levels, has been asymptomatic for the past 12 hours with no new ECG changes. Echocardiography shows normal LV function .

In terms of further assessment,what would you do next?

|[pic] |Inpatient coronary angiography | |

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|[pic] |Radionuclide angiogram | |

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|[pic] |Out-patient exercise stress test | |

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|[pic] |Exercise stress test prior to discharge |[pic]Your answer |

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|[pic] |Discharge home on medications | |

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This patient has had a non-ST-elevation myocardial infarction, which is associated with a low risk of in-hospital mortality, unlike ST-segment elevation MI. However, the 6-month mortality rate exceeds that of ST-segment elevation MI. A symptom-limited, Bruce-protocol exercise test can be done prior to discharge. Patients who can complete 9 minutes without chest pain, ischaemic changes in ECG or arrhythmias have an excellent prognosis (annual mortality rate 1%) and do not require further investigation.

18. A 54-year-old man presents with an irregular tachycardia of around 130 bpm. He played in a cricket match the previous day and consumed 28 units of alcohol on the evening of the match. On examination his blood pressure is 95/50 mmHg. What is the most likely diagnosis?

|[pic] |Ventricular tachycardia | |

|[pic] |Sick-sinus syndrome | |

|[pic] |Paroxysmal atrial fibrillation |[pic]Your answer |

|[pic] |Atrial flutter | |

|[pic] |Sinus tachycardia | |

|This man has paroxysmal atrial fibrillation as evidenced by his irregular fast tachycardia. Episodes of tachycardia in this |

|condition may occasionally be precipitated by an excess intake of alcohol or caffeine. Other causes may be acute myocardial |

|infarction, atrial septal defect, or pre-excitation syndromes such as Wolff–Parkinson–White. Atrial flutter is associated with an |

|absolutely regular rhythm of 150–220 bpm. |

|Standard therapy for atrial fibrillation of recent onset is electrical cardioversion, providing there are no contraindications. |

|Intravenous flecainide may be considered for chemical cardioversion in the absence of a history of ischaemic heart disease; |

|amiodarone is an acceptable alternative. Long-term prophylaxis with agents such as sotalol may be required. |

19. A 20-year-old woman presents with a history of dyspnoea on exertion. On examination she has a wide, fixed, split-second sound with an ejection systolic murmur (III/VI) in the left second intercostal space. Her ECG shows left axis deviation.

What is the most probable diagnosis?

|[pic] |Ostium primum septal defect |[pic]Your answer |

|[pic] |Tricuspid incompetence | |

|[pic] |Ostium secondum septal defect | |

|[pic] |Pulmonary stenosis | |

|[pic] |Aortic stenosis | |

|Wide, fixed splitting of S2 with an ejection systolic murmur in the left second intercostal space points to a diagnosis of atrial |

|septal defect. Left axis deviation occurs in ostium primum atrial septal defect, whereas right axis deviation is seen in ostium |

|secondum septal defect. The ejection systolic murmur is due to a large volume of blood passing through the pulmonary valves into |

|the pulmonary artery. |

|Aortic stenosis is associated with an ejection systolic murmur that is usually diamond-shaped (crescendo–decrescendo). There may |

|be a systolic ejection click. Tricuspid incompetence presents with a blowing pansystolic murmur, best heard on inspiration at the |

|lower left sternal edge. In pulmonary stenosis, there is a harsh mid-systolic ejection murmur, best heard on inspiration to the |

|left of the sternum in the second intercostal space. |

20. Normal pregnancy is associated with which one of the following haemodynamic changes?

|[pic] |A 20% reduction in blood volume and cardiac output | |

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|[pic] |A 10 mmHg drop in diastolic blood pressure toward the end of pregnancy |[pic]Your answer |

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|[pic] |Bradycardia with a radial pulse rate between 45 and 55 beats per minute | |

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|[pic] |Grade 2/6 diastolic murmur at the mitral area | |

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|[pic] |Pulsus alternans | |

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Despite an expansion of the plasma volume and cardiac output of 50%, mean and diastolic blood pressures fall by approximately 15% owing to a reduction in peripheral vascular resistance. Tachycardia rather than bradycardia is a recognised physiological change during pregnancy. It is a consequence of reduced peripheral vascular resistance and fall in blood pressure levels. The heart may be slightly enlarged and may be displaced outward because of the high diaphragm. A pulmonary systolic murmur from a high blood flow is common and there may be a physiological third heart sound. Diastolic murmurs are generally pathological and at the mitral area may signify mitral stenosis. The presence of pulsus alternans usually signifies advanced heart failure.

21. A 16-year-old girl presents to the Emergency Department with a collapse and palpitations after attending her end-of-term school disco. Only medication history of note includes a recent antibiotic prescription for an infected toe. Past medical history includes allergy to penicillin. Family history reveals that her mother died suddenly at the age of 34 when the daughter was 3 years old. One aunt and one uncle have also passed away suddenly. Electrocardiogram (ECG) reveals sinus rhythm in the Emergency Department but the QT interval is prolonged at 550 ms (corrected).

Which of the following conditions is most likely to be related to her collapse?

|[pic] |Wolff–Parkinson–White type A | |

|[pic] |Wolff–Parkinson–White type B | |

|[pic] |Congenital long QT syndrome |[pic]Your answer |

|[pic] |Lown–Ganong–Levine syndrome | |

|[pic] |Ebstein's anomaly | |

The QT prolongation and history of sudden death in the family suggests the possibility of congenital long QT syndrome. Her presentation may have occurred because QT interval can be prolonged in association with a number of medications that include erythromycin (prescribed for her foot), ketoconazole, antihistamines, anti-arrhythmics and a number of other agents. The condition is associated with torsades de pointe ventricular tachycardia. Lange–Nielsen syndrome is one syndrome of QT prolongation, which has been described in association with congenital deafness; Romano–Ward syndrome is associated with normal hearing. The Lown-Ganong-Levine syndrome (LGL) is usually considered in a class of preexcitation syndromes that includes the Wolff-Parkinson-White syndrome (WPW), LGL, and Mahaim-type preexcitation. Theories proposed to explain LGL have centered around the possible existence of intranodal or paranodal fibers that bypass all or part of the atrioventricular (AV) node. Criteria for LGL include PR interval less than or equal to 0.12 second (120 ms), normal QRS complex duration, and occurrence of supraventricular tachycardia but not atrial fibrillation or atrial flutter.

22. A 70-year-old man is brought into A&E. He is unwell with a cool periphery and blood pressure of 70/40 mmHg. ECG shows a regular broad-complex tachycardia with rate of 150 bpm. He is unable to provide a clear history, but a recent prescription in his wallet shows that he is taking aspirin, ramipril, frusemide and spironolactone. What is the likely arrhythmia?

|[pic] |Atrial fibrillation | |

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|[pic] |Atrial flutter with a 2:1 block | |

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|[pic] |SVT with aberrant conduction | |

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|[pic] |VT |[pic]Your answer |

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|[pic] |Wolff–Parkinson–White syndrome | |

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This patient is haemodynamically compromised as a consequence of the arrhythmia. The prescription would suggest the presence of underlying cardiac disease with probable cardiac dysfunction. In the context of known ischaemic heart disease or left ventricular dysfunction, a broad-complex tachycardia should be assumed to be VT until proved otherwise. Many ECG criteria exist to aid the differentiation of VT and SVT with aberrancy and include: A–V dissociation; capture beats; fusion beats; extreme QRS axis; concordance across ventricular leads. A previous ECG can be exceedingly helpful. Subtle clinical signs, such as intermittent cannon waves in the JVP and a variable first heart sound may be present, in patients with A–V dissociation.

23. A 47-year-old man with chest pain of 1-hour duration is diagnosed as having acute myocardial infarction.

Which of the following features, if present, would most contraindicate thrombolytic therapy?

|[pic] |Blood pressure 160/110 mmHg | |

|[pic] |History of likely ischaemic stroke within the past month |[pic]Your answer |

|[pic] |ST-segment elevation in ECG | |

|[pic] |Previous aspirin therapy | |

|[pic] |Elevated serum cholesterol | |

There is an approximate 1% risk of stroke and a 0.7% risk of major haemorrhage associated with the use of thrombolysis. Recombinant tissue plasminogen activator (TPA) is connected with a lower rate of intracranial haemorrhage and hence is the drug of choice for thrombolysis in acute myocardial infarction of less than 12 hours’ duration. A list of the absolute contraindications to thrombolytic use is shown below;

• Aortic dissection

• Previous cerebral haemorrhage

• Known history of cerebral aneurysm or arteriovenous malformation

• Known intracranial neoplasm

• Recent (within the past 6 months) thromboembolic stroke

• Active internal bleeding (excluding menstruation)

• Patients previously treated with streptokinase or an isolated plasminogen streptokinase activator complex (APSAC or anistreplase) should receive recombinant tissue plasminogen activator, reteplase, or tenecteplase.

24. A 57-year-old man with ischaemic heart disease, and a recent transient ischaemic attack, is prescribed clopidogrel. How would the mechanism of action of this drug be best described?

|[pic] |Blocks glycoprotein IIb/IIIa receptors | |

|[pic] |Blocks thrombin receptors | |

|[pic] |Blocks thromboxane production | |

|[pic] |Blocks platelet ADP receptors |[pic]Your answer |

|[pic] |Potentiates antithrombin-III action | |

Clopidogrel blocks platelet ADP receptors, while aspirin blocks thromboxane production, hence the complementary actions of the two drugs when given together following coronary stenting. The final common pathway for platelet aggregation is through the glycoprotein IIb/IIIa receptor. Hence, the most powerful antiplatelet drugs are the glycoprotein IIb/IIIa blockers such as abciximab and tirofiban. Hirudins act by blocking thrombin receptors but have no current indication in cardiac disease.

25. Cardiac catheterisation is performed on a 25-year-old man with a systolic murmur but no symptoms. ECG and chest X-ray are normal. The findings are as follows (pressures mmHg): aorta, 125/70; left ventricle, 120/12; right atrium, mean 8; right ventricle, 40/8; pulmonary artery, 44/14; pulmonary capillary wedge, mean 13. Saturations (%): aorta, 97; superior vena cava, 68; right atrium, 70; right ventricle, 82; pulmonary artery, 85.

What is the most likely cardiac diagnosis?

|[pic] |ASD – primum | |

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|[pic] |ASD – secundum | |

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|[pic] |Mitral stenosis | |

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|[pic] |Primary pulmonary hypertension | |

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|[pic] |Ventricular septal defect |[pic]Your answer |

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The catheter data demonstrate a step up in saturations from the right atrium to the right ventricle, in keeping with a left to right shunt at the level of the ventricle. There is a mild elevation in pulmonary artery pressure in keeping with the shunt. VSD is the commonest form of congenital heart disease. In adults a small defect may present as an asymptomatic murmur; or in the extreme as Eisenmenger’s syndrome, where reversal of a left to right shunt has occurred as a consequence of advanced pulmonary hypertension. VSD is associated with an increased risk of endocarditis and hence antibiotic prophylaxis is recommended. Management depends upon the actual size of the shunt.

26. A 54-year-old man is referred with increased swelling of his ankles and abdomen, and a degree of shortness of breath on exertion. His jugular venous pressure is elevated with prominent x- and y-descents. Apex beat is normal. ECG shows atrial fibrillation with widespread non-specific ST-segment abnormalities. Echo reveals preserved left ventricular systolic function with biatrial enlargement and an estimated pulmonary artery systolic pressure of around 60 mmHg. Chest X-ray shows atrial enlargement but no other abnormalities.

What is the most likely cardiac diagnosis?

|[pic] |Chronic pulmonary emboli | |

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|[pic] |Dilated cardiomyopathy | |

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|[pic] |Restrictive cardiomyopathy |[pic]Your answer |

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|[pic] |Secundum ASD | |

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|[pic] |Tricuspid regurgitation | |

| |  | |

Restrictive cardiomyopathy results from fibrosis or infiltration of the endo- or myocardium. The result is failure of the ventricles to relax, with a subsequent increase in ventricular end-diastolic pressures leading on to biatrial enlargement. Systolic function is normal. Underlying causes include amyloidosis, storage disorders, sarcoidosis, haemochromatosis and endomyocardial fibrosis. Symptoms are usually those of predominant right heart failure and atrial fibrillation is common. The ECG may be normal but diffuse ST-segment and T-wave changes are commonly seen. Diuretics are the mainstay of symptomatic treatment. It can be very difficult to differentiate restrictive cardiomyopathy from constrictive pericarditis. In restriction the pulmonary artery systolic pressure is usually elevated to > 45 mmHg, while it is lower in constriction. Right and left heart catheter may aid differentiation.

27. A 30-year-old-man presents to the outpatient clinic with a 2-month history of progressive effort intolerance. Some three weeks ago he experienced an episode of shortness of breath at rest, suggestive of paroxysmal nocturnal dyspnoea. Examination reveals a JVP raised up to his earlobes, a soft tender hepatomegaly and a bilateral pitting oedema up to his knees. Chest examination reveals bibasal crepitations, and an audible S3 on auscultation of the heart. The chest X-ray shows cardiomegaly with interstitial infiltrates. Echocardiography shows global left ventricular hypokinesia with an ejection fraction of 25–30%.

Which of the following is the LEAST likely aetiological factor?

|[pic] |Alcohol abuse | |

| |  | |

|[pic] |Genetic factor | |

| |  | |

|[pic] |Adenovirus | |

| |  | |

|[pic] |Eosinophilic states |[pic]Your answer |

| |  | |

|[pic] |HIV infection | |

| |  | |

Dilated cardiomyopathy encompasses a heterogeneous group of conditions. Alcohol abuse is an important aetiological factor in a significant number of patients. About 25% of cases are inherited as an autosomal-dominant trait. A substantial group is due to a late autoimmune reaction to viral myocarditis. Up to 10% of patients with advanced HIV infection develop dilated cardiomyopathy. Eosinophilic states are associated with obliterative cardiomyopathy.

28. As medical registrar on call you are summoned to assist with a cardiac arrest on CCU. A 60-year-old man is being resuscitated having presented with unstable angina 3 days before. He has had three unsuccessful shocks for ventricular fibrillation and is receiving his second cycle of cardiopulmonary resuscitation. An anaesthetist is looking after his airway. He has a large-bore iv access in his antecubital fossa.

What additional therapy would you consider at this point?

|[pic] |Amiodarone |[pic]Your answer |

| |  | |

|[pic] |Bretylium | |

| |  | |

|[pic] |Calcium chloride | |

| |  | |

|[pic] |Lidocaine | |

| |  | |

|[pic] |Sodium bicarbonate | |

| |  | |

Current recommendations for advanced life support in the UK are provided by the European Resuscitation Council and the Resuscitation Council UK. In patients with refractory ventricular fibrillation or pulseless VT (ie after three initial shocks) intravenous amiodarone should be considered. The standard dose used is a 300-mg bolus. If central access is available this is the desired route. However, if this is not the case then a large-bore peripheral access can be used. Lidocaine (lignocaine) is used when amiodarone is unavailable.

29. Which of the following statements is true regarding pulsus alternans?

|[pic] |It is found in beriberi heart disease | |

| |  | |

|[pic] |The pulse is irregular | |

| |  | |

|[pic] |It is diagnosed electrocardiographically | |

| |  | |

|[pic] |It is found in association with a third heart sound |[pic]Your answer |

| |  | |

|[pic] |It is found in patients with pericardial effusion | |

| |  | |

Pulsus alternans is found in patients with acute left ventricular failure. Alternate weak and strong pulses occur, which are regularly placed. A pathological third heart sound is usually associated. The condition may be associated with heart failure or pericarditis for example, but is not usually seen in association with pericardial effusion. Beri-Beri heart disease leads to long QT, T wave inversion and low voltage complexes.

Electrical alternans is diagnosed electrocardiographically. The amplitude of QRS complexes varies alternately. It occurs due to changes in electrical depolarisation,  conduction abnormalities or cardiac motion.

30. A 56-year-old lady has a known ventricular septal defect. Which of the following clinical signs would most indicate the presence of established pulmonary hypertension?

|[pic] |Loud systolic murmur | |

|[pic] |Raised jugular venous pressure (JVP) |[pic]Your answer |

|[pic] |Single loud second heart sound | |

|[pic] |Systolic thrill | |

|[pic] |Displaced apex beat | |

The systolic murmur and thrill of the ventricular septal defect (VSDs) are absent once Eisenmenger's complex has developed. Under these circumstances there are just signs of pulmonary hypertension and cyanosis. Cardiomegaly may occur with Eisenmenger's complex because of right venticular (RV) enlargement but the left ventricle (LV) is not usually significantly enlarged and the apex beat is not typically displaced. A single second heart sound is characteristically associated with Fallot’s tetralogy where pulmonary stenosis protects from developing pulmonary hypertension.

31. A 20-year-old woman complains of recurrent syncope. Each attack has occurred after attending an aerobics class. On examination, a systolic murmur is heard which worsens with the Valsalva manoeuvre and improves on squatting. What could be the diagnosis?

|[pic] |Epilepsy | |

| |  | |

|[pic] |Hypertrophic obstructive cardiomyopathy |[pic]Your answer |

| |  | |

|[pic] |Atrial fibrillation | |

| |  | |

|[pic] |Aortic stenosis | |

| |  | |

|[pic] |Vasovagal attack | |

| |  | |

Dyspnoea is usually the most common complaint of patients with hypertrophic obstructive cardiomyopathy. However, angina or syncope may also occur. A left ventricular apical impulse, a prominent S4 gallop and a harsh systolic ejection murmur are typical findings in these cases. Valsalva manoeuvre decreases venous return to the heart, which results in a smaller ventricular size. This leads to an increase in the murmur. An echocardiogram is the diagnostic procedure of choice. Most patients with pure or predominant aortic stenosis have gradually increasing obstruction for years but do not become symptomatic until their sixth to eighth decades.

32. A 45-year-old man with a strong family history of ischaemic heart disease presents with atypical chest pains. Electrocardiographic (ECG) exercise testing shows J point depression of 1 mm with a heart rate of 120 beats/min (bpm). What is the most appropriate next step?

|[pic] |Coronary angiography | |

|[pic] |Dobutamine stress echocardiography | |

|[pic] |Radionuclide myocardial perfusion scanning | |

|[pic] |Reassure and discharge |[pic]Your answer |

|[pic] |Repeat ECG exercise testing on anti-anginal medication | |

J point depression is a physiological response to an increase in heart rate and ST segments should, therefore, be measured 80 ms post-J. J point depression produces upward sloping ST depression which has little predictive value for coronary artery disease. Horizontal and downward sloping segments are more predictive than upward sloping ones. In a young man with atypical chest pain, this exercise test would be reassuring and there would be no indication for further investigation or treatment.

33. A 68-year-old man is admitted with syncope. He is known to have ischaemic cardiomyopathy. His medications include: aspirin 75 mg od, frusemide 80 mg bd and lisinopril 10 mg od. An initial ECG shows sinus bradycardia (50 bpm) and RBBB. Results of blood tests are as follows: sodium, 134 mmol/l; potassium, 3.5 mmol/l; creatinine 124 μmol/l. He has recurrent syncopal episodes on the CCU, where monitoring shows episodes of non-sustained torsades de pointes (polymorphic VT). Which of the following would be your initial line of treatment?

|[pic] |DC cardioversion | |

| |  | |

|[pic] |Intravenous amiodarone | |

| |  | |

|[pic] |Intravenous magnesium |[pic]Your answer |

| |  | |

|[pic] |Oral metoprolol | |

| |  | |

|[pic] |Temporary pacing | |

| |  | |

Torsades de pointes (polymorphic VT with QRS complexes of different amplitude twisting around isoelectric line) occurs in patients with a prolonged QT interval. Any cause of QT prolongation can predispose to the arrhythmia.  These include: congenital (the Jervell–Lange-Neilsen or Romano–Ward syndromes); with QRS complexes of different amplitutetwisi metabolic (hypo-calcaemia, -magnesaemia or –kalaemia); drugs (eg amiodarone, tricyclic antidepressants, phenothiazines); ischaemic heart disease; mitral valve prolapse. The arrhythmia often occurs in the context of bradycardia. The key here is that amiodarone may exacerbate the situation. Intravenous magnesium (even if the serum magnesium concentration is normal) is the first-line therapy. Temporary pacing at higher rates with or without β-blockers is the next line of therapy. DC shock would not be helpful since episodes are non-sustained.

34. A 67-year-old man is admitted with chronic congestive heart failure. Based on this history, what is the most important factor to be kept in mind when prescribing drugs for this patient?

|[pic] |Loop diuretic administration would result in a decrease in mortality | |

|[pic] |Digoxin is more effective than ACE inhibitors in providing symptomatic relief | |

|[pic] |Administration of a β-blocker reduces the time spent in hospital |[pic]Your answer |

|[pic] |Administration of spironolactone has no effect on the incidence of sudden cardiac death | |

|[pic] |Angiotensin II-receptor antagonists have a better response rate than ACE inhibitors | |

|Beta-adrenoceptor blocking agents (metoprolol, bisoprolol and carvedilol) have been found to be useful in patients with chronic |

|stable heart failure. The studies MERIT and CIBIS 2, using the β-blockers metoprolol and bisoprolol, respectively, have shown |

|improved symptomatic class, exercise tolerance, left ventricular function and reduced mortality in heart failure of any cause. The|

|rapid decrease in symptoms reduces the time spent in hospital. |

|Diuretic administration is associated with a rapid decrease in symptoms, but mortality rates are unchanged. Angiotensin-converting|

|enzyme (ACE) inhibitors and diuretics are recommended in all patients with clinical heart failure as ACE inhibitors reduce |

|mortality rates by 20%. Spironolactone greatly reduces the mortality and sudden cardiac death rates and should be added to the |

|treatment. A recent trial comparing an angiotensin II-receptor antagonist (losartan) with an ACE inhibitor (enalapril) has shown |

|no benefit of the former over the latter. Angiotensin II-receptor antagonists should be used when ACE inhibitors are |

|contraindicated or cause side-effects (eg persistent cough). |

35. Aortic stenosis in adults is commonly the result of which one of the following?

|[pic] |Bicuspid aortic valve disease |[pic]Your answer |

| |  | |

|[pic] |Left ventricular membrane | |

| |  | |

|[pic] |Hypertrophic obstructive cardiomyopathy (HOCM) | |

| |  | |

|[pic] |Rheumatic fever | |

| |  | |

|[pic] |Cystic medial necrosis | |

| |  | |

Approximately 1% of the general population has a bicuspid aortic valve defect. The bicuspid aortic valve may function normally throughout life, with late stenosis resulting from fibrocalcific thickening. Aortic stenosis resulting from bicuspid valve disease occurs from increasing rigidity of the abnormal aortic valve and increasing calcification. The congenital form of bicuspid valve disease is conjoined anteriorly.

36. A 60-year-old man with NYHA (New York Heart Association) class II heart failure, is taking angiotensin-converting enzyme (ACE) inhibitors and ß-blockers for his heart failure. He is generally well in himself. On direct questioning at his routine outpatient visit, it is noticed that his exercise tolerance has decreased over the last year. Which of the following drugs should be added to his list of medications?

|[pic] |Digoxin | |

|[pic] |Frusemide | |

|[pic] |Isosorbide mononitrate | |

|[pic] |Spironolactone |[pic]Your answer |

|[pic] |Valsartan | |

The European Society of Cardiology recommends the addition of spironolactone for improving the survival of patients who are in the transition from well-controlled class II to class III or IV heart failure. Diuretics are only indicated if there is fluid retention. Angiotensin-receptor blockade in addition to ACE (angiotensin-converting enzyme) inhibitors is not recommended at this stage. Digoxin helps to relieve symptoms to some extent, and is more useful if the patient is in atrial fibrillation. Similarly, nitrates and hydralazine help to improve symptoms in patients with class III and IV heart failure.

37. A 36-year-old old woman presents with a cerebral infarct following treatment for a deep vein thrombosis. Cardiovascular examination is entirely normal. The most likely underlying cardiac abnormality is?

|[pic] |Partial anomalous pulmonary venous drainage | |

|[pic] |Ostium primum atrial septal defect (ASD) | |

|[pic] |Ostium secundum ASD | |

|[pic] |Common atrium | |

|[pic] |Patent foramen ovale |[pic]Your answer |

The incidence and importance of patent foramen ovale (PFO) remain controversial but up to 25% of people have a PFO which may allow passage of a thrombus from the venous to systemic circulation when the right heart pressures are increased – characteristically with Valsalva or following a pulmonary embolus. PFOs are not associated with clinical signs and cannot normally be identified on transthoracic echo. Use of agitated saline contrast during echo is helpful in identifying PFOs. ASDs are much less common than PFOs and abnormal clinical signs are usually present. Partial anomalous pulmonary venous drainage means that between one and three pulmonary veins open into the right atrium rather than the left atrium. There is no increased risk of right-to-left shunting.

38. A 67-year-old lady during pre-operative assessment is found to have a small pericardial effusion located posteriorly on routine Echocardiography. Electrocardiogram (ECG) is entirely normal. What is the next most appropriate step in her management?

|[pic] |Cardiac catheterisation | |

|[pic] |Reassure |[pic]Your answer |

|[pic] |Pericardiocentesis | |

|[pic] |Diuretics | |

|[pic] |Computed tomography (CT) of the heart | |

Once the diagnosis of pericardial effusion has been made, it is important to determine whether the effusion is creating significant haemodynamic compromise. Asymptomatic patients without haemodynamic compromise, even with large pericardial effusions, do not need to be treated with pericardiocentesis unless there is a need for fluid analysis for diagnostic purposes (eg in acute bacterial pericarditis, tuberculosis, and neoplasias)

39. A 70-year-old woman with long-standing hypertension is referred to out-patients with a diagnosis of asymptomatic atrial fibrillation. Echocardiography demonstrates normal left ventricular function, mild LVH and normal mitral valve structure. The left atrium is slightly enlarged (4.2 cm). She is not keen on cardioversion and her rate is well controlled at 70 bpm. What would be the optimal strategy for long-term anticoagulation?

|[pic] |Aspirin | |

| |  | |

|[pic] |Clopidogrel | |

| |  | |

|[pic] |Dipyridamole | |

| |  | |

|[pic] |Low molecular weight heparin | |

| |  | |

|[pic] |Warfarin |[pic]Your answer |

| |  | |

Atrial fibrillation (AF) is common and affects around 2–5% of the population who are over 60 years old. It confers an approximately fivefold increased risk of stroke. The absolute risk of stroke is related to the coexistence of other cardiovascular disease. In patients with AF and additional risk factors for stroke, such as hypertension, warfarin has been shown to be superior to antiplatelet therapy (primarily aspirin). This patient has evidence of structural cardiac disease with LVH and an enlarged left atrium, thereby reflecting a higher risk of developing a thromboembolic complication. Ongoing studies are evaluating the role of combined antiplatelet therapy, eg aspirin and clopidogrel.

40. A 35-year-old woman presented with a history of intermittent light-headedness. Clinical examination and 12-lead electrocardiogram (ECG) were normal. Which of the following, if present on a 24 hour Holter ECG tracing, would be the most clinically important?

|[pic] |Atrial premature beats | |

|[pic] |Profound sleep-associated bradycardia | |

|[pic] |Supraventricular tachycardia |[pic]Your answer |

|[pic] |Transient Mobitz type-1 atrioventricular block | |

|[pic] |Ventricular premature beats | |

Both atrial and ventricular premature beats are normal variants when seen on a 24 hour Holter electrocardiogram (ECG) tracing. Profound bradycardia may also occur during sleep and is a normal finding. Mobitz type-1 atrioventricular block carries less clinical significance than Mobitz type-2 because the risk of progression to complete heart block is much lower. Thus supraventricular tachycardia (SVT) carries the most clinical significance. Diagnosis of the underlying cause is based on the presence or absence of P-waves and P-wave morphology. Patients can be taught carotid sinus massage to avert SVTs at home, or adenosine can be used in non-asthmatic patients for acute cardioversion to sinus rhythm. Class III anti-arrythmics, such as sotalol, may be considered for prophylaxis.

41. The first-line treatment for a 50-year-old man with known poor left ventricular function who presents with a broad complex tachycardia at a rate of 150 beats/min (bpm) and a blood pressure of 120/70 mmHg is?

|[pic] |Amiodarone |[pic]Your answer |

|[pic] |β-blockers | |

|[pic] |Flecainide | |

|[pic] |Lidocaine | |

|[pic] |Verapamil | |

In the presence of poor left ventricular function, broad complex tachycardia is highly likely to be caused by ventricular tachycardia (VT). Verapamil may precipitate circulatory collapse in VT and is therefore contraindicated. In the presence of severe left ventricular (LV) dysfunction, negative inotropes such as lidocaine and β-blockers are undesirable while flecainide may rarely cause degeneration of stable tachycardias to ventricular fbrillation (VF). Amiodarone is, therefore, the most appropriate choice.

42. A 55-year-old obese woman presents to the casualty department with worsening dyspnoea and ankle swelling due to end-stage heart failure. Her renal functions are within normal limits and her potassium is 4.4 mmol/l. Which of the following combinations of drugs is best suited for her in terms of mortality benefit?

|[pic] |Ramipril, amiloride and bendrofluazide | |

|[pic] |Ramipril, amiloride, bendrofluazide and atenolol | |

|[pic] |Ramipril, frusemide and bendrofluazide | |

|[pic] |Ramipril, frusemide, bendrofluazide and atenolol | |

|[pic] |Ramipril, frusemide, bendrofluazide, bisoprolol and spironolactone |[pic]Your answer |

Currently, end-stage heart failure is an indication for combined ACE inhibitor and ARB (angiotensin II-receptor antagonist) treatment. Potassium sparing diuretics have generally been avoided in patients receiving ACE inhibitors, owing to the potential risk of hyperkalaemia. However a small dose of spironolactone (25mg) in combination with ACEI is relatively safe when the renal function remains intact as in this patient.

43. An obese 50-year-old woman suddenly develops dyspnoea and hypotension 2 days after undergoing a total abdominal hysterectomy. There is mild jugular venous distension with prominent A waves. The lung fields are clear. ECG shows tachycardia with a right bundle-branch block and minor ST-segment changes.

What is the most likely diagnosis?

|[pic] |Acute myocardial infarction | |

|[pic] |Pulmonary embolism |[pic]Your answer |

|[pic] |Aspiration pneumonia | |

|[pic] |Aortic dissection | |

|[pic] |Pneumothorax | |

Pulmonary embolism presents with a raised jugular venous pressure (JVP) and right bundle-branch block due to acute right heart failure. Hypotension in an acute MI would cause gross ST-segment abnormalities on ECG. Clear lung fields on auscultation preclude a diagnosis of pneumonia. Aortic dissection would cause an MI or aortic regurgitation before causing respiratory distress.

44. A 68-year-old woman recently diagnosed with multiple myeloma presents to her GP with progressively increasing breathlessness, exercise intolerance and ankle swelling. On examination, there is bilateral pitting leg oedema to her thighs, ascites and raised JVP. The apical impulse is impalpable. An ECG shows diffusely diminished voltage. Chest X-ray is normal and the echocardiogram shows small thick ventricles and dilated atria with a thickened interatrial septum. The ventricular myocardium has a granular sparkling texture on echo, and minimal fluid in the pericardial space is noted. What is the most likely diagnosis?

|[pic] |Chronic pericardial effusion with tamponade | |

|[pic] |Chronic pericardial effusion without tamponade | |

|[pic] |Constrictive pericarditis | |

|[pic] |Restrictive cardiomyopathy |[pic]Your answer |

|[pic] |Congestive heart failure | |

Cardiac involvement is the most common cause of death in patients with amyloidosis associated with an immunocyte dyscrasia – typically as restrictive cardiomyopathy. Physical examination reveals right heart failure with a raised jugular venous pressure (JVP), characteristically showing a prominent deep Y descent. The heart size is often normal. The physical findings are very similar in constrictive pericarditis (CCP), but the apex is frequently non-palpable due to the thick pericardium. The chest X-ray may show pericardial calcifications in patients with constrictive pericarditis. The most characteristic ECG finding of restrictive cardiomyopathy is diffusely diminished voltages. Echocardiography typically shows small thick ventricles and a thick interatrial septum due to amyloid deposits, which have a ‘granular sparkling’ appearance. Pericardial effusion is common, but rarely causes tamponade.

45. Which of the following is the commonest cardiovascular abnormality seen in an adult patient with Marfan’s syndrome?

|[pic] |Aortic regurgitation | |

| |  | |

|[pic] |Aortic root dilatation |[pic]Your answer |

| |  | |

|[pic] |Mitral regurgitation | |

| |  | |

|[pic] |Mitral annular calcification | |

| |  | |

|[pic] |Aortic dissection | |

| |  | |

Marfan’s syndrome is a connective tissue disorder that is inherited as an autosomal-dominant trait. There is considerable variation in its clinical manifestations. The ocular (dislocation of the lens), skeletal (arachnodactyly, joint hypermobility, scoliosis, chest deformity and high arched palate) and cardiovascular systems (aortic root dilatation (70%) and mitral valve prolapse (60%)) are characteristically involved. Weakening of the aortic media leads to a fusiform ascending aortic aneurysm, which may be complicated by aortic regurgitation and aortic dissection.

Mitral regurgitation can result from mitral valve prolapse, dilatation of a mitral valve annulus or mitral annular calcification. Pregnancy is particularly hazardous. Treatment with ß-blockers reduces the rate of aortic dilatation and the risk of rupture.

46. A 19-year-old boy has been admitted to the emergency department with syncope. He felt hot, complained of nausea and then fainted. His electrocardiogram (ECG) was normal. A cousin suffers from epilepsy.

What is the most appropriate investigation?

|[pic] |Electroencephalogram (EEG) | |

|[pic] |24-h ECG | |

|[pic] |Computed tomography (CT) of the brain | |

|[pic] |Echocardiography | |

|[pic] |Tilt test |[pic]Your answer |

The development of tilt testing has allowed the study of the pathophysiology of neurocardiogenic syncope. The patient is strapped to a tilt-table and is tilted, head upright, usually at 70 degrees for up to 45 min. Protocols that use additional provocation with isoprenaline or nitrates are also commonly used. Blood pressure and cardiac rhythm are monitored throughout the tilt test. In neurocardiogenic syncope, the patient classically maintains normal blood pressure initially, until the sudden onset of syncope is associated with severe hypotension and bradycardia, often preceded by tachycardia. These features resolve with return to the supine posture. Some patients have a mainly vasodepressor response, with hypotension and little change in heart rate, while others have a marked cardioinhibitory response, with severe bradycardia or asystole of several seconds’ duration. However, most patients exhibit a mixed response, and those patients with marked cardioinhibition also have a preceding vasodepressor response. This is an important observation when treatment is considered, since permanent pacing to maintain cardiac rhythm may not cure all symptoms, because falls in blood pressure may still occur even when bradycardia is prevented.

47. A 45-year-old man attends for review. He has been suffering increasing shortness of breath over the past few years. He is a non-smoker who drinks 20 units per week of alcohol and has no significant past cardiovascular history. Now he presents with what seems to have been a transient ischaemic attack (TIA), with weakness and co-ordination problems affecting his left side, which have resolved over the past 24 hours. On examination blood pressure is 142/95 mmHg and he is in sinus rhythm. There is no opening snap, but a diastolic murmur is heard which changes in character according to posture. Bloods are unremarkable, including C-reactive protein (CRP), which is in the normal range.

 

Which of the following diagnoses fit best with this clinical picture?

 

|[pic] |Right atrial myxoma | |

| |  | |

|[pic] |Left atrial myxoma |[pic]Your answer |

| |  | |

|[pic] |Aortic stenosis | |

| |  | |

|[pic] |Mitral stenosis | |

| |  | |

|[pic] |Mitral regurgitation | |

| |  | |

This patient has suffered a TIA, most likely due to embolus from an intra-cardiac cause. One possible clinical explanation could be mitral stenosis, left atrial enlargement and atrial fibrillation, leading to clot formation within the atrium, but this patient is in sinus rhythm, there is no opening snap on auscultation, and the murmur changes in character with posture. This suggests the possibility of another cause, and left atrial myxoma would fit the bill. Myxoma can occur in any cardiac chamber, but occurs most commonly in the left atrium. It is a gelatinous, friable tumour, which leads to transient signs of mitral stenosis that only occur if the tumour approaches the mitral valve orifice. There is no opening snap. There may be an early diastolic plop as the tumour prolapses through the mitral valve. X-ray may show calcification within the tumour if it is long standing. Definitive treatment involves surgical excision; recurrence rate is extremely low, but follow up is recommended for a period of 5 years. Right atrial myxomas are more rare and difficult to identify clinically; there may be evidence of multiple pulmonary infarcts due to formation of emboli.

48. A 65-year-old man is admitted with a broad complex tachycardia. Which one of the following features would suggest a diagnosis of supraventricular tachycardia with aberrancy rather than ventricular tachycardia?

|[pic] |Capture beats on the electrocardiogram (ECG) | |

|[pic] |Past history of ischaemic heart disease | |

|[pic] |Right bundle branch block morphology with left axis deviation on the ECG | |

|[pic] |Temporary alleviation by carotid sinus massage |[pic]Your answer |

|[pic] |Variable intensity of the first heart sound | |

Ventricular tachycardia (VT) may be distinguished from supraventricular tachycardia (SVT) by ECG features that indicate AV dissociation (ie that the atria and ventricles are no longer linked in rate and rhythm). The three characteristic features of AV dissociation are irregular notching of the QRS complex, capture beats and fusion beats. A variable intensity of the first heart sound in a regular tachycardia suggests AV dissociation causing variable filling of the ventricles from the atria. Atrial fibrillation is the commonest cause of variable intensity of the first heart sound. VT does not involve the AV node and cannot therefore be affected by adenosine or carotid sinus massage, which temporarily blocks the AV node. A past history of ischaemic heart disease is associated with a >95% chance that broad complex tachycardia is VT.

49. An 18-year-old student is admitted from a night club in a state of collapse. On admission to A&E his blood pressure is 90/45 mmHg, and he has a pulse of 190 per minute. ECG reveals a narrow complex tachycardia, which is terminated with adenosine. ECG after termination of the tachycardia reveals a PR interval of approximately 100 ms, and a slurred QRS complex with delta wave. What diagnosis fits best with this clinical picture?

|[pic] |Amphetamine overdose | |

|[pic] |Cocaine overdose | |

|[pic] |Hypokalaemia-induced arrhythmia | |

|[pic] |Wolff–Parkinson–White syndrome (WPW) |[pic]Your answer |

|[pic] |Lown–Ganong–Levine syndrome | |

|WPW syndrome (due to accessory cardiac conduction pathway) presents with paroxysmal tachycardias in 10% of patients aged 20–40 |

|years, and 35% of sufferers aged over 60 years. |

|Common types of arrhythmia at presentation include reciprocating tachycardia at 150–250 bpm (80%), atrial fibrillation (15%) and |

|atrial flutter (5%). Thankfully, presentation with ventricular tachycardia is rare. Prevalence in the UK population is around |

|0.15%, being more frequent in males. Most WPW patients have a normal heart structure, but there may be associated mitral valve |

|prolapse, cardiomyopathy or Ebstein’s anomaly in certain patients. ECG abnormalities are characterised by the presence of a PR |

|interval < 120 ms and a QRS complex >120 ms with slurred, slowly rising onset (delta wave). The Lown–Ganong–Levine syndrome is |

|characterised by a short PR interval and normal QRS complex on ECG. |

|Narrow complex tachycardias may be terminated acutely with adenosine or verapamil or cardioversion. Digoxin should not be used as |

|it may accelerate tachycardias. In the non-acute stage, radiofrequency ablation of the accessory pathway may be attempted. |

50. Which of the following is a feature of coarctation of the aorta?

|[pic] |If it occurs above the left subclavian artery, blood pressure elevation may be evident only in the left | |

| |arm | |

|[pic] |It is associated with a continuous murmur | |

|[pic] |It is usually accompanied by a bicuspid aortic valve |[pic]Your answer |

|[pic] |It presents with the inability to augment cardiac output with exercise | |

|[pic] |Surgical correction usually resolves the hypertension | |

Coarctation of the aorta usually occurs just distal to the origin of the left subclavian artery. If it arises above the left subclavian, blood pressure may be elevated only in the right arm. A continuous murmur is heard only if the obstruction is severe. A diastolic murmur of aortic regurgitation may be heard, as a bicuspid aortic valve commonly accompanies this condition. Cardiac output response to exercise is not affected unless there is cardiac failure. Hypertension is the major problem and may persist even after complete surgical correction.

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