Cardio Practice Qs

Question 1

A 76-year-old women presents in your clinic with complaining that sometimes when shes going up the stairs she feels faint. Upon taking her history she has stable angina, dyspnoea and heart failure. You suspect she has a heart valve problem.

a) What would you expect aortic stenosis to sound like and explain the pathophysiology?

Answer 1

Collapsing water hammer pulse
Early diastolic murmur *might b wrong is late
Leakage of blood into the left ventricle
During diastole due to ineffective coaptation of aortic cusps

Question 2

If this woman had mitral stenosis, what would you expect to see on a chest X-ray?

Answer 2

Enlarged left and right ventricles.
It must be noted that cardiac echos not XR are the better investigation for cardiac murmurs.

Question 3

What does mitral stenosis sound like on auscultation?

Answer 3

Pansytolic murmur Soft S1 sound

Question 4

A 43-year-old women presents in your clinic with exertional dyspnoea, fatigue, and a nocturnal cough with pink frothy sputum. You examine her and from this diagnose her with heart failure.

a) List some clinical signs you might find on examination or on a chest X-ray.

Answer 4

3rd/4th heart sounds
Crepitations in lung bases.
ABCDE – alveolar oedema, Kerley B lines, cardiomegaly, dilated upper lobe vessels, effusions

Question 5

What marker might you find in her blood that could be indicative of heart failure?

Answer 5

Brain natriuretic peptide, troponin I, troponin T, creatine kinase

Question 6

A 35 year old male presented to the A&E who was very febrile. On further questioning, the patient also has headaches, shortness of breath and arthralgia. On examination, it was noted that there were nail bed splinter haemorrhages, Osler’s nodes and Janeway lesions of the hands.

List 3 investigations that you would want to do for initial investigations of infective endocarditis.

Answer 6

Infective endocarditis is an infection of the endocardium of the heart, commonly this affects the valvular structures.

1st line investigations would often include:
* FBC – anaemia, leucocytosis
* Urinalysis – proteinuria, RBC casts, WBC casts
* Blood cultures – recommend 3 sets prior to starting antibiotics
* ECG
* Echocardiogram

Question 7

Define atherosclerosis

Answer 7

Accumulation of lipids, macrophages, and smooth muscle cells in the intima of large and medium sized arteries.

Question 8

List 5 risk factors that can lead to hypertension

Answer 8

Renal disease e.g. renal artery stenosis
Obesity
Pregnancy induced hypertension / pre-eclampsia
Endocrine causes e.g. hyperaldosteronism
High alcohol intake
Metabolic syndrome
Diabetes mellitus
Age >60yrs
FHx of hypertension or coronary artery disease
High salt intake >1.5g/day
Low fruit and vegetable intake
Dyslipidaemia
Physical inactivity
Smoking

Question 9

Give 2 medical and 2 lifestyle interventions that are indicated in the management of ischaemic heart disease in a primary care setting.

Answer 9

Antihypertensives Statins
Aspirin

Diabetic therapy / encouraging better glycaemic control
Smoking cessation
Advice on diet
Encouraging exercise

Question 10

A 59-year-old man is seen in the Emergency Department after reporting retrosternal crushing chest pain of 10/10 intensity. He reports the pain is radiating down the left arm and neck. An ECG reveals ST-segment elevation in leads V1 to V6.

a) Other than chest pain, name 4 other symptoms or signs you may find on the history or examination (4 marks)

Answer 10

Symptoms – nausea/vomiting, light-headed/dizzy, short of breath, sweating/diaphoresis, anxiety/dread, palpitations.

Signs – pallor, hypotensive, sweating/diaphoresis.

Question 11

Name 3 modifiable and 2 non-modifiable risk factors for a STEMI

Answer 11

Modifiable – smoking, hypertension, diabetes, obesity, physical inactivity, poor diet, cocaine use, dyslipidaemia, metabolic syndrome

Non-modifiable – advanced age, male sex, family history of CAD, previous CAD
Give leniency if a valid risk factor falls into a grey area between modifiable and non- modifiable, for example diabetes could fall into either category.

Question 12

A 1-day-old infant born at full term is noted to have cyanosis of the oral mucosa. On examination, respiratory rate is 40 and pulse oximetry is 80%. Congenital heart disease is suspected and Tetralogy of Fallot is diagnosed after echocardiography.

Name the 4 cardiac defects involved in Tetralogy of Fallot.

Answer 12

• Ventricular septal defect (VSD)
• Pulmonary stenosis
• Right ventricular hypertrophy
• Overriding/misplaced aorta.

Question 13

A 68-year-old male presents to the Emergency Department with worsening shortness of breath. A chest X- ray shows classic findings of heart failure.

Name 3 findings that may be seen on the chest X-ray.

Answer 13

CXR findings in heart failure is a classic medical school question.
A helpful way to remember is ABCDE:

A – Alveolar oedema (also called bat wings)
B – Kerley B lines (horizontal lines in lower posterior lung fields)
C – Cardiomegaly (cardiac diameter >0.5 width of the thorax)
D – Dilated upper lobe vessels (also called cephalisation)
E – Pleural effusion (shown as blunting of the costophrenic angles)

Question 14

Describe the differences between 1st, 2nd (type I and II), and 3rd degree heart block. (8 marks)

1st degree –

2nd degree type I (Mobitz I or Wenckebach) –

2nd degree type II (Mobitz II) –

3rd degree –

Answer 14

1st degree - indicated on an ECG by a prolonged PR interval (the time between atrial depolarisation and ventricular depolarisation)

Mobitz I – has progressive prolongation of the PR interval followed by a dropped QRS complex

Mobitz type II second degree AV block is a disease of the distal conduction system (His-Purkinje system). Characterised by intermittently non-conducted P waves not preceded by PR prolongation and not followed by PR shortening

3rd degree heart block is the complete absence of AV conduction. Atrial rate is ~100 bpm, ventricular rate ~40 bpm. 2 rates are independent.

Question 15

A pulmonary embolism can be caused by a deep vein thromboembolism.

a) Define thrombosis and embolism.

Answer 15

Embolism = blocked vessel caused by a foreign body e.g. a blood clot or an air bubble

Thrombosis = formation of a blood clot inside a blood vessel, this obstructs the flow

Question 16

What the difference between infarction and ischaemia?

Answer 16

Infraction = death of heart muscles cells due to a reduced or absent blood supply

Ischaemia = restriction in blood supply to tissues causing a shortage of oxygen that is needed for cell function

Question 17

Renin is released from the kidney in response to decreased renal perfusion (caused by fluid loss and hypovolaemia). This activates the renin-angiotensin-aldosterone system.

List 4 effects of RAAS activation.

Answer 17

• Increased sympathetic activity
• Increased tubular reabsorption of Na and Cl. K+ excretion. H2O retention.
• Increased aldosterone secretion resulting in Na reabsorption in DCT.
• Arteriolar vasoconstriction
• ADH secretion leading to H2O reabsorption
• Overall salt and water retention and an increase in BP.

Question 18

What is the difference between essential hypertension and secondary hypertension?

Answer 18

Essential hypertension occurs independent of any identifiable cause.

Secondary hypertension occurs as a result of an identifiable cause

Question 19

Name 3 causes of secondary hypertension outlining a mechanism of action for each

Answer 19

Renal artery stenosis
Chronic renal disease
Primary hyperaldosteronism
Stress
Sleep apnea
Hyper- or hypothyroidism
Pheochromocytoma
Preeclampsia
Aortic coarctation

Question 20

A 59-year-old male presents in A&E with a crushing chest pain that radiates to the jaw or shoulder for the past 30 minutes. He also feels short of breath and nauseous. O2 is 96% and you carry out an ECG and note that there is ST elevation in leads V3, V4.
What part of the heart is likely to be affected by this MI?

a) Superior
b) Anterior
c) Inferior
d) Left lateral
e) Right lateral

Answer 20

B. V1-4 shows the anterior/septal region of the heart. See diagram below.
This typically shows as an infarction in the left anterior descending (LAD) artery

Question 21

An ECG is taken on someone suspected of suffering a myocardial infarction. They show abnormalities in leads II, III, and aVF.
Which coronary artery is most likely to be implicated?

a) Septal branches only of the LAD
b) Left anterior descending
c) Left coronary artery
d) Right coronary artery
e) Circumflex artery

Answer 21

D. Right coronary artery

The inferior leads are the ones mentioned in the question.
These stem from the right coronary artery which supplies the right atrium and right ventricle.

Question 22

A 59-year-old male presents in A&E with a crushing chest pain that radiates to the jaw or shoulder for the past 30 minutes. He also feels short of breath and nauseous. O2 is 96% and you carry out an ECG and note that there is ST elevation in leads V3, V4.
Which would NOT be involved in your acute management of this STEMI?

a) Aspirin
b) Morphine
c) Nitrates
d) Oxygen
e) All of the above options would be indicated

Answer 22

D. Oxygen

MONA – morphine, O2, nitrates, aspirin is the easy way to remember the acute management of an MI however O2 is only indicated if sats are <94%.

Question 23

A 59-year-old male has recently suffered a myocardial infarction. The junior doctor looking over the medications in his discharge summary and notices a mistake.
Which of the following would not be involved in the management of a previous MI if there was no contra- indications?

a) Aspirin
b) Verapamil
c) Atorvastatin
d) Propranolol
e) Ramipril

Answer 23

B. Verapamil

NICE CKS – the following drugs should be offered following an MI (provided no contra-indications) as the have been shown to reduce the risk of further MI and other cardiovascular events.
* ACE inhibitor – ramipril. Or ARB e.g. candesartan
* Dual antiplatelet therapy e.g. clopidogrel and aspirin
* Beta blocker e.g. propranolol
* Statin e.g. atorvastatin

Calcium channel blockers e.g. verapamil are only given if beta blockers are contra-indicated.

Question 24

Which of the following is not a chest x-ray finding in chronic heart failure?

a) Pleural effusions
b) Kerley B lines
c) Cardiomegaly
d) Alveolar oedema
e) Dilation prominent in lower lobe vessels

Answer 24

E. Dilation prominent in lower lobe vessels

The way to remember XR findings in HF is ABCDE.
* A – alveolar oedema
* B – Kerley B lines
* C – cardiomegaly
* D – dilation of UPPER lobe vessels
* E – effusions

Upper lobe venous diversion (cephalisation) is caused by an increase in left atrial pressure (receives from pulmonary system) which can occur in pulmonary oedema. Produces a stag sign on a frontal CXR which is produced when atrial pressure rises from 5-10mmHg to 10-15mmHg.

Question 25

Which of the following may show ST-segment elevation on an ECG?

a) Unstable angina
b) Pritzmetal angina
c) Cardiomyopathy
d) Stable angina
e) NSTEMI

Answer 25

B. Pritzmetal angina

Prinzmetal angina may show ST elevation on an ECG along with STEMI and pericarditis.

• Unstable angina would often be normal or can show ST depression and flat T waves.
• Stable angina will show no changes.
• NSTEMI will show ST depression, deep T wave inversion and pathological Q waves.

Question 26

A 70-year-old female presents to her GP with a history of progressive shortness of breath with exertion over a period of 4 months with no associated chest pain. She has a past medical history of type 1 diabetes mellitus which is well controlled and currently takes amlodipine 10mg once daily for hypertension. On further questioning, the patient has also mentioned that she is often breathless whilst lying in her bed at night. On physical examination there is mild hepatomegaly and pitting oedema. Which of the following blood investigation is most appropriate at this stage?

a) Urea and electrolytes
b) HbA1c
c) B-type natriuretic peptide
d) Blood Cultures
e) Atrial natriuretic peptide

Answer 26

C. B-type natriuretic peptide

(BNP or NT- proBNP)

The presentation is typical of heart failure and therefore NT-proBNP would be the most appropriate blood test.
BNP is released from the heart (mainly ventricles) in response to stretch, it is a marker for HF.

• U&E are useful but are not diagnostic in this instance.
  8 HbA1c looks at glycated Hb over the last 120 days
• Blood cultures would be indicated if infection was suspected.
• ANP is released mainly from the atria in response to stretch.

Question 27

A 25-year-old male attended to A&E due to sudden onset of palpitations in his chest. He described this as his heart was skipping a beat. On examination it was found that the patient had a SVT.
Which of the following would be the most appropriate in the acute management of this patient to return to normal sinus rhythm?

a) Valsalvar manoeuvre
b) Amiodarone
c) Atropine
d) DC cardioversion
e) Adrenaline

Answer 27

A. Valsalvar manoeuvre

The patient in the question has a supra-ventricular tachycardia. SVT are a form of narrow complex tachycardia and therefore the as the patient is young, the first line in this case would be valsalva manoeuvre which is where the nose and mouth is held during forceful expiration to stimulate the vagus nerve to return the heart into sinus rhythm.

• Amiodarone would be used in a broad-complex tachycardia.
• Atropine and adrenaline would be used during an episode of bradycardia to speed the heart up.
• DC cardioversion would not be first line in this management.

Question 28

A 70-year-old man has a routine check-up at his local GP. He is found to have a new diagnosis of atrial fibrillation after an ECG.
Which of these is a tool that assesses starting anticoagulation in patients with stroke risk due to atrial fibrillation?

a) ABCD2
b) HAS-BLED
c) CHA2DS2-VASc
d) QRISK3
e) Well’s Criteria

Answer 28

C. CHA2DS2-VASc

Screening tools such as ABCD2, QRISK3 and FRAX are common topic to come up in exams. Knowing which tools do what is more important than knowing each factor that is used to calculate a score. The CHA2-DS2-VASc or just CHADS2 score both estimate stroke risk in patients with AF.

*ABCD2 – estimates risk of stroke after a suspected TIA.
*HAS-BLED – estimates risk of bleeding on patients on anticoagulation
*QRISK3 – estimates risk of developing a heart attack or stroke in next 10 years.
*Well’s criteria – estimates risk of Pulmonary Embolism in clinical presentation.

Question 29

A 76-year-old woman present to her GP with shortness of breath on exertion. She felt it has been gradually worsening over the past 6-months. She denies any chest pain but says that she wakes up in the middle of the night gasping for breath. Her legs are oedematous on examination.
Which of these investigations is first line for her diagnosis?

a) CT Chest
b) B-Natriuretic peptide
c) Ankle brachial pressure index (ABPI)
d) Echocardiogram
e) ECG

Answer 29

B. B-Natriuretic peptide

This patient has a likely diagnosis of with key factors such as shortness of breath on exertion, paroxysmal nocturnal dyspnoea, and peripheral oedema.

An ECG, echocardiogram and CXR are all good investigations, but you should remember a BNP or NT- proBNP as the first line investigation, especially in primary care.

Question 30

A 54-year-old woman presents with shortness of breath on exertion, fatigue, and palpitations. On examination, her jugular venous pressure is elevated, and a pan-systolic, high-pitched “whistling” murmur is heard. The murmur radiates to the left axilla.
What is the likely cause of the murmur?

a) Mitral regurgitation
b) Mitral stenosis
c) Aortic stenosis
d) Aortic regurgitation
e) Hypertrophic cardiomyopathy

Answer 30

a) Mitral regurgitation

• aortic stenosis which causes an ejection-systolic murmur
• and mitral regurgitation which causes a pan-systolic murmur
• aortic regurgitation which causes an early diastolic murmur
• mitral stenosis which causes a mid-diastolic murmur.

Question 31

A 63-year-old black man presents for a check-up at his GP. He has no significant past medical history but admits to a poor diet. His blood pressure is 153/95 mmHg and the GP wants to start medical management.
Which of the following medications is most appropriate?

a) Amlodipine
b) Ramipril
c) Bisoprolol
d) Candesartan
e) Indapamide

Answer 31

A) Amlodipine

Getting familiar with the NICE guidelines is important for your 2a exams. Hypertension medical management is a common topic, because of how common hypertension is and the slight complexity with two different patient groups.

If a patient is under 55 or has type 2 diabetes an ACEi or ARB should be started.

If a patient is black or over 55 then a CCB such as amlodipine should be started.

Question 32

What is the most appropriate diagnostic investigation for aortic stenosis?

a) Chest X-ray
b) ECG
c) Echocardiogram
d) Auscultation
e) Exercise tolerance test

Answer 32

C) Echocardiogram

• Aortic stenosis is the obstruction of blood flow across the aortic valve due to aortic calcification; presents with SoB with exertion, angina, or syncope. Characteristic murmur is systolic mid to late peaking with a crescendo-decrescendo pattern, radiation to the carotids. Doppler echo is essential for diagnosis and will show a pressure gradient across the stenotic aortic valve. Valve replacement is the treatment.
• CXR is unlikely to reveal much, calcification may be visible in larger arteries. LV hypertrophy may occur due to increased pressure required to pump blood through aortic valve.
• ECG is used in the diagnosis of aortic stenosis. Demonstrates LV hypertrophy and absent Q waves, AV block, BBB. In AS patients 90% of the ECGs recorded show some abnormality.
• Trans-thoracic echo (including Doppler) is the best test for the initial diagnosis and subsequent evaluation of AS. The sensitivity and specificity of the test are high. Elevated aortic pressure gradient; measurement of valve area and LV ejection fraction.
• Exercise tolerance test is and ECG that is recorded whilst you are exercising. Used to test for coronary heart disease and angina.
• Auscultation is one method of detecting heart murmurs but is not the most appropriate diagnostic investigation.

Question 33

A 82-year-old woman came to clinic to receive her COVID-19 vaccine. Shortly after its administration she felt short of breath and a rash started developing all over her body. She collapsed a minute later.
What is the first medication which should be administered?

a) Salbutamol
b) High flow oxygen
c) Adrenaline
d) IV fluids
e) Chlorpheniramine

Answer 33

C) Adrenaline

The resuscitation council’s algorithm for anaphylaxis says: 1. ABCDE 2. Check for obvious potential diagnosis 3. Call for help 4. Adrenaline 5. Establish airway / high flow O2 / IV fluid challenge / chlorphenamine / hydrocortisone
Adrenaline is the first medication to be given, opens airway and blood vessels helping to reverse the effects of anaphylaxis. 500 micrograms (0.5 mL) of 1:1000 IM.

• Chlorpheniramine is an antihistamine which takes 15-20 mins to work.
• Histamine release is the cause of anaphylaxis so this helps reverse the effects.
• Hydrocortisone is a corticosteroid, its benefit in anaphylaxis is still unproven but aims to stop a biphasic reaction, reduce the symptom reoccurrence, and wheezing.
• Intravenous fluids are given as large volumes of fluid may leak from the patient’s circulation. Signs of shock, vasodilation and a low BP.
• Salbutamol is a beta 2 adrenergic agonist which causes bronchodilation helping the patient to breathe during anaphylaxis.

Question 34

A 45-year-old male recently had a coronary artery bypass graft (CABG) after suffering an myocardial infarction 2 weeks ago. He now has a sharp pain in his chest which is radiating to his left shoulder and is worse when he takes a deep breath in. He says the pain is lessened when he is sat forward compared to when he is lying flat. On examination, his vital signs are normal and there are no murmurs on auscultation. His troponin blood test comes back normal.
What is the most likely diagnosis?

a) Pericarditis
b) Interstitial lung disease
c) Endocarditis
d) Myocardial infarction
e) Aortic dissection

Answer 34

A) Pericarditis

Pericarditis – this is inflammation of the membrane that surrounds the heart, movement of the heart causes pain. It causes pleuritic pain which is classically sharp and worse on inspiration. Pericarditis pain is relieved when leaning forward. It can occur after a CABG as the tissue has been damaged, another cause is Dressler Syndrome whereby pericarditis occurs as a complication of an MI 2-3 weeks afterwards. They may have a fever, this is not present in this description

• Endocarditis – inflammation of heart valves typically caused by staph or streptococci. History is usually IV drug user or previous dental surgery. The tricuspid valve as this is the first valve blood passes from the systemic circulation so is affected after systemic infection. The patient will have a fever, murmur over the affected valve, numerous signs on examination – roth spots, splinter haemorrhages, Janeway lesions, Osler’s nodes.
• Myocardial infarction – pain wouldn’t typically change depending on position, though it does radiate to the left shoulder which is typical. This option can be ruled out as the troponin blood test that detects recent MIs is negative.
• Aortic dissection – separation of the media lamina resulting in blood entering the wall of the aorta. Presentation is classically acute chest pain radiating to the back between the scapulae. Physical examination will show unequal blood pressure in arms.

Question 35

A 75-year-old man presents to his GP with recurrent, intermittent, sudden-onset chest pain and shortness of breath. He reports that he often tires easily climbing the stairs in his house. It has now worsened, and he experiences the pain more often even at rest. Past medical history is significant for hypertension and type II diabetes. An ECG demonstrates mild ST-segment depressions in V1-V2. Cardiac troponins are not elevated.
What is the most likely diagnosis?

a) NSTEMI
b) STEMI
c) Prinzmetal angina
d) Stable angina
e) Unstable angina

Answer 35

E) Unstable angina

Unstable angina is incomplete coronary artery occlusion usually by a thrombus, atherosclerotic plaque has ruptured which causes a clot to form and occlude the artery. The pain now occurs at rest and worsens on exercise. ST segment depressions and T wave inversions. No elevation of biomarkers.

• Stable angina is typically secondary to atherosclerosis partially occluding the coronary artery. Pain occurs on exercise when O2 demand is higher. This is relieved with nitrates and rest. May show ST depressions.
• STEMI – full width infarction of the myocardial tissue caused by occlusion of a coronary artery. ST elevation, peaked T waves, Q waves. Biomarkers are positive.
• NSTEMI – partial infarction of the myocardial tissue caused by occlusion of a coronary artery. ST depression and T wave inversion. Biomarkers are positive.
  Prinzmetal angina is a spasm in the coronary artery, it shows a dramatic ST elevation during episodes. Relieved with nitrates. Occurs unrelated to activity levels.

Question 36

A 57-year-old man, who has recently undergone prosthetic valve surgery, presents with a 5-day history of high fever and night sweats. He admits to infrequent IV heroin use. On examination, you notice some dark red lines under his fingernails and some painful red spots over his hands and soles of his feet.
What is the most likely diagnosis?

A. Pericarditis
B. Systemic Lupus Erythematosus (SLE)
C. Infective Endocarditis
D. Rheumatic heart disease
E. Henoch-Schonlein Purpura

Answer 36

C. Infective Endocarditis is correct - there are risk factors of prosthetic valves and IV drug use, alongside splinter haemorrhages and Osler’s nodes.

A. Pericarditis typically presents with a history of a viral infection, with acute onset chest pain that is characteristically relieved by leaning forward.
B. SLE can present with splinter haemorrhages, but Osler’s nodes are not characteristic
D. Rheumatic heart disease does present with subcutaneous nodules, but also alongside arthritis, chorea and a specific skin rash. It tends to present in children/younger adults.
E.HSP typically presents with a red/purple rash up the back of the legs and buttocks.

Question 37

A 75-year-old man presents to A&E with sharp chest pain, which is worse when he lies down, but improves when he leans forward. He has been feeling under the weather for the past week with a viral chest infection. You suspect pericarditis, and are concerned about the possible signs and complications that could develop.
Which of the following is the correct definition of cardiac tamponade?

A. An exaggerated drop in blood pressure of over 10mmHg on inspiration
B. Accumulation of a small amount of fluid in the pericardial cavity that does not
reduce cardiac function
C. A paradoxical rise in Jugular Venous Pressure on inspiration
D. Persistent inflammation of the pericardium that results in fibrosis, limiting diastolic filling of the heart
E. Accumulation of a large amount of fluid in the pericardial cavity that compresses the heart and reduces cardiac function

Answer 37

E. Accumulation of a large amount of fluid in the pericardial cavity that compresses the heart and reduces cardiac function - This is the correct definition of cardiac tamponade.

A. This is the definition of Pulsus Paradoxus, which is a sign of cardiac tamponade
B. This is the definition of Pericardial Effusion - basically a less extreme version of cardiac tamponade
C. This is the definition of Kussmaul’s sign, which is a sign of cardiac tamponade
D. This is the definition of constrictive pericarditis, which can only be distinguished from cardiac tamponade by cardiac catheterisation (present the same clinically as they both restrict filling of the heart)

Question 38

Which of the following features is not a feature of the Tetralogy of Fallot?

A. Overriding aorta
B. Left ventricular hypertrophy
C. Ventricular Septal Defect
D. Pulmonary artery stenosis
E. Right ventricular hypertrophy

Answer 38

B. The four features of the tetralogy of Fallot are an overriding aorta, VSD, pulmonary artery stenosis and right ventricular hypertrophy. RV hypertrophy occurs in response to pulmonary artery stenosis, to try and maintain cardiac output. This means there is a right to left shunt through the VSD, resulting in cyanosis due to deoxygenated blood entering the oxygenated circulation. Left ventricular hypertrophy is not a feature.

Question 39

An 86-year-old woman has long-standing ischaemic heart disease, which has recently progressed to left-sided heart failure.
Which of these features would you not expect to see in left-sided heart failure?

A. Ascites
B. Dyspnoea
C. Reduced ejection fraction
D. Orthopnoea
E. Normal JVP

Answer 39

A. Ascites is a feature of right-sided heart failure, as it causes congestion in the systemic system, resulting in accumulation of fluid

• B. You would expect dyspnoea (difficulty breathing) in left-sided heart failure, as it causes pulmonary congestion
• C. A reduced ejection fraction occurs when the systolic function of the LV is reduced, meaning the volume of blood pumped out of the heart is less than the volume of blood that enters the LV during diastole. There isn’t always a reduced ejection fraction in left-sided heart failure, as the cause may be diastolic, meaning the volume moving in and out of the heart would be the same.
• D. Orthopnoea (difficulty breathing when lying down) is a classic symptom of heart failure. The severity can be measured by asking the patient how many pillows they use to sleep with.
• E. JVP may be raised in right-sided heart failure, as it occurs when there is systemic congestion, due to raised venous pressure. It is not raised in left-sided heart failure.

Question 40

A 68-year-old man presents with a two-week history of shortness of breath when lying down. He is worried because he has been waking up suddenly in the middle of the night feeling like he cannot breathe. You suspect the patient has heart failure, and want to order a blood test to support your diagnosis.
Which hormone levels should you test, and where is this released?

A. Brain Natriuretic Peptide (BNP), which is released from the hypothalamus
B. Atrial Natriuretic Peptide (ANP), which is released from the hypothalamus
C. Brain Natriuretic Peptide (BNP), which is released from the ventricles
D. Atrial Natriuretic Peptide (ANP), which is released from the atria
E. Brain NatriureticPeptide(BNP),which is released from the posterior pituitary gland

Answer 40

C. Brain Natriuretic Peptide (BNP), which is released from the ventricles

BNP is released by the ventricles in response to overstretching of the walls of the heart (i.e. when heart failure leads to fluid overload). Raised levels support a diagnosis of heart failure, and normal/low levels exclude heart failure as a diagnosis. ANP is released by the atria, but this is not measured in the diagnosis of heart failure.

Question 41

A 55-year-old man with longstanding hypertension and diabetes presents to A&E with a 3-hour history of excruciating chest pain that radiates to his left shoulder. He appears pale and sweaty, and has worsening dyspnoea despite sitting down. You perform an ECG, which shows ST depression.
What is the most likely diagnosis?

A. Stable angina
B. STEMI
C. Decubitus angina
D. NSTEMI
E. Unstable angina

Answer 41

D. NSTEMI - this is correct, as chest pain radiating to the left shoulder with dyspnoea are classic symptoms of an MI. This is confirmed with the ECG, which shows ST depression.

A. Stable angina only occurs on exertion, and improves when the person stops exerting themselves, unlike in this case.

B. The clinical features align with a diagnosis of a STEMI, however this is excluded due to ST depression on the ECG, and a STEMI has ST elevation

C. Decubitus angina is a type of angina that occurs when the person lies down

E. Unstable angina is an onset of chest pain at rest, but you would not expect other features such as going pale or the pain radiating to the shoulder. A more classic presentation would be someone who used to get chest pain on exertion who is starting to get episodes of pain when they are sitting still, rather than such an acute presentation.

Question 42

A 39-year-old woman presents to A&E with tachycardia, tachypnoea and cool peripheries. Her pulse is weak and she is very confused. You suspect she is going into hypovolaemic shock.
Which of the following is not a possible cause of hypovolaemic shock?

A. Ruptured aortic aneurysm
B. Severe burns
C. Pyelonephritis leading to urosepsis
D. Vomiting
E. Trauma to the leg causing bleeding

Answer 42

C. Pyelonephritis leading to urosepsis, Urosepsis can lead to septic shock, but this is not a cause of hypovolaemic shock as there is no blood/fluid loss

A. A ruptured aortic aneurysm has a mortality rate of 80% due to the rapid onset of hypovolaemic shock from internal blood loss
B. Severe burns result in loss of fluid, meaning the circulating volume is depleted
D. Hypovolaemic shock is caused by anything that results in a depleted circulating volume, therefore vomiting is a possible cause as it can lead to dehydration
E. Bleeding from the leg will reduce circulating volume so can cause hypovolaemia

Question 43

A patient presents to A&E with a myocardial infarction. The consultant performs an ECG, which shows ST-elevation in leads II, III and avF.
Which coronary artery is occluded?

A. Left Circumflex Artery
B. Left Anterior Descending Artery C. Left Coronary Artery
D. Right Marginal artery
E. Right Coronary Artery

Answer 43

E. Right Coronary Artery

The Right Coronary Artery supplies the inferior surface of the heart, which corresponds to leads II, III and aVF.
Leads I, v5, v6 and aVL = Lateral = Circumflex Leads v3 and v4 = Anterior = LAD

Question 44

A 42-year-old woman comes to the GP with concerns about her atrial fibrillation. You are unsure if she needs anticoagulation medication to prevent a stroke, so decide to use a risk score tool to guide your decision.
Which risk score is most appropriate?

A. Wells score
B. CHAD2DS2-Vasc score
C. FRAX score
D. ABCD2 score
E. HAS-BLEDscore

Answer 44

B. CHAD2DS2-Vasc score

CHAD2DS2-Vasc score is used to calculate the risk of having a stroke in patients with atrial fibrillation.

• HAS-BLED score (E) calculates the risk of having a major bleed within 1 year in patients with atrial fibrillation.
• Wells score (A) is used to calculate the risk of venous thromboembolism.
• FRAX score (C) is used to calculate the risk of having a fracture within the next 10 years.
• ABCD2 score (D) is used to calculate the risk of having a stroke after a TIA.

Question 45

A 56-year-old man presents to hospital feeling light-headed and dizzy, after he ‘felt his heart race’ earlier this morning. He has a history of diabetes and smokes 20 cigarettes a day. You decide to perform an ECG, which shows increasingly prolonged PR intervals, followed by a drop in a QRS complex.
What is the most likely diagnosis?

A. Left bundle branch block
B. Right bundle branch block
C. Mobitz type 1 second-degree heart block
D. Mobitz type 2 second-degree heart block
E. Third-degree heart block

Answer 45

C. Mobitz type 1 second-degree heart block

The most likely diagnosis is Mobitz type 1 second-degree heart block (C). This is due to the increasingly long PR intervals and drop in QRS complexes, giving a characteristic Wenckebach pattern.

• Mobitz type 2 (D) presents similarly with a drop in QRS complexes, but the PR intervals remain a constant length.
• Third-degree heart block (E) presents with no association between atrial and ventricular contraction.

Question 46

A 68 year old man presents to Accident and Emergency with severe chest pain. He has a past medical history of obesity, hypertension and has smoked since the age of 17. The pain is described as coming on suddenly at rest and tearing in nature radiating to his back as well as migrating down.
What is the most likely diagnosis?

A. Aortic dissection
B. Anterior Myocardial Infarction
C. Angina
D. Costochondritis
E. Gastroesophageal reflux

Answer 46

A. Aortic dissection
This stem gives a classic history of Aortic dissection.

• An Anterior Myocardial Infarction typically causes a crushing central chest pain radiating to the neck/left arm not typically down the body.
• Angina is typically associated with pain on exertion and relieved by rest.
• The pain in Costochondritis is typically an achy pain felt towards the front of the chest.
• Gastroesophageal reflux is typically a retrosternal burning chest pain often related to meals, lying down or straining.

Question 47

A 19 year old woman presents to her GP as she has been experiencing episodes of her heart racing and feeling light headed needing to sit down. An ECG is performed on which the doctor notices an abnormality associated with Wolff-parkinson-white syndrome.
Which ECG abnormality is most associated with Wolff-parkinson-white syndrome?

A. Delta wave
B. Convex ST elevation
C. Saddle ST elevation
D. Bifid p wave
E. Increase PR interval

Answer 47

A. Delta wave
a Delta wave is caused by the accessory conduction pathway in WPW.

• Increased PR interval is wrong as the PR interval should decrease in WPW.
• Convex ST elevation indicates infarction.
• Saddle ST elevation indicates pericarditis.
• Bifid p wave indicates left martial enlargement.

Question 48

A 54 year old lady is brought into Accident and Emergency by her husband after a collapse while they were out hiking in which she cut her arm. The loss of consciousness was brief and she recovered quickly.
On further questioning she reveals that she has had many episodes like this before but this is the first time she has injured herself and subsequently presented to hospital. Her past medical history is unremarkable except for suffering from rheumatic fever as a child.
On examination it is noted she has a slow rising weak pulse before moving on to auscultation.
Which clinical finding would you most likely find upon auscultation?

A. Constant machinery murmur
B. Ejection systolic murmur
C. Pansystolic murmur
D. Parasternal heaves
E. Rumbling mid diastolic murmur

Answer 48

B. Ejection systolic murmur
]given the typical Aortic stenosis history an Ejection systolic murmur is most likely.

• Pansystolic murmur would indicate mitral regurgitation.
• Parasternal heaves, although a possible sign in aortic stenosis this sign is picked up on palpation and auscultation.
• A Rumbling mid diastolic murmur indicates Mitral stenosis.
• A Constant machinery murmur indicates a patent ductus arteriosus.

Question 49

Foetal circulation allows oxygenated maternal blood to circulate around the fetus and bypass the lungs. To allow the circulation to bypass the lungs there is a vessel that connects the pulmonary arteries to the aorta.
What is the name of this structure before it closes?

A. Ductus arteriosus
B. Ductus venosus (allows blood to by pass the liver)
C. Ligamentum arteriosum
D. Ligamentum venosum
E. Umbilical artery

Answer 49

A- this is the Ductus arteriosus being described, the remnant of this is the Ligamentum arteriosum in adults.

• The Ductus venosus allows blood to bypass the liver, the remnant of which is the Ligamentum venosum in adults.
• The umbilical arteries, found in the abdominal and pelvic regions, supply deoxygenated blood from the fetus to the placenta.

Question 50

A 64 year old man presents to his GP three weeks after he had a myocardial infarction. He is concerned as he has been having central chest pain again but says this time it is different. This time the pain is worse on breathing in or lying flat and is relieved by leaning forward. On examination he has a fever and a friction rub can be heard on auscultation.
Which of the following is most likely the cause of this presentation?

A. Angina
B. Dressler’s syndrome
C. Infective endocarditis
D. Myocardial infarction
E. Pneumonia

Answer 50

B. Dressler’s syndrome develops 2 to 10 weeks post MI. It is thought that myocardial injury stimulates the formation of antibodies against the heart muscle. Classic symptoms include fever, chest pain and plural pain with a pericardial rub. Treatment involves aspirin, NSAID or steroids.

Question 51

Which of the following is not a typical finding seen in heart failure on a chest radiograph?

A. Alveolar edema
B. Cardiomegaly
C. Dilated prominent lower lobe vessels
D. Interstitial edema
E. Pleural effusion

Answer 51

C- Dilated prominent upper lobe vessels are seen in heart failure not lower lobe vessels.

The ABCDE mnemonic can help remember the x-ray findings in heart failure.

Alveolar oedema, Kerley B lines (Interstitial oedema) Cardiomegaly, Dilated prominent upper lobe vessels and Pleural effusion

Question 52

A 54 year old intravenous drug user presents to Accident and Emergency with a 8 day history of fever and fatigue. On examination he has poor dental hygiene and many positive signs including a new murmur.
Which of these findings would you most likely see on fundoscopy of the eye?

A. Clubbing
B. Hederden’s nodes
C. Janeway’s lesions
D. Roth spots
E. Splinter hemorrhages

Answer 52

D. Roth spots (retinal haemorrhage with pale centers) are the only sign in the eye in this list the rest are signs that would be found on the hand. Although Hederden’s nodes are seen on the hands, these are seen in Osteoarthritis not endocarditis (Osler’s nodes are seen in endocarditis).

Question 53

Steve has type 2 diabetes and is a CEO of a large company who has recently been working from home. He is usually active and looks after himself but has found it difficult to control food intake, done less exercises and started smoking again due to stress.
Which of the following for Steve is an unmodifiable risk factor of cardiovascular disease?

A. Age
B. Diabetic control
C. Diet
D. Physical inactivity
E. Stress

Answer 53

A. Age is the only unmodifiable risk factor, the rest can all be modified.

Question 54

A 58 year old woman with a past medical history of hypertension presents to GP with worsening shortness of breath on exertion over the last few months. The shortness of breath is also worse lying down and so she sleeps on many pillows at night. She is also concerned that she has been coughing up sputum which is described as pink frothy. fine crackles on auscultation.
Given this history, what is the most likely diagnosis?

A. Left sided heart failure
B. Pneumothorax
C. Pneumonia
D. Pericarditis
E. Right sided heart failure

Answer 54

A. The symptoms in this history point towards Left sided heart failure. Right sided heart failure, although would have fatigue. signs of RHF differ and include a raised JVP, pitting edema and ascites. A Pneumothorax would present typically with sudden onset SOB or pain. Pneumonia, although SOB would be present the sputum would be green/yellow. Pericarditis is also less likely with this history.

Question 55

Which of the following is an example of secondary prevention of cardiovascular disease?

A. A cardiovascular risk assessment at a health checkup
B. Antiplatelet therapy post MI
C. Eating a balanced diet
D. Percutaneous coronary intervention
E. Stopping smoking

Answer 55

A. is an example or secondary prevention. Methods to detect and address an existing disease prior to the appearance of symptoms.

C and E are examples of primary prevention and D is a possible treatment for a MI.

Question 56

A 66 year old man presents to his GP with a history of central, crushing chest pain on exertion radiating to the jaw, relieved by rest within a few minutes. Examination of the chest is unremarkable, however the patient has a background of obesity, type 2 diabetes mellitus and a 30 pack-year smoking history.
What is the most appropriate first-line test to reveal the likely diagnosis?

A. Invasive coronary angiography
B. Resting12-leadECG
C. Myocardial perfusion scintigraphy
D. Resting transthoracic echocardiogram
E. CT coronary angiography

Answer 56

E. NICE recommend CT coronary angiography (E) as the first-line investigation in patients with symptoms typical for stable angina.

Invasive coronary angiography (A) is reserved for if other sipler investigations are inconclusive.

A resting 12-lead ECG (B) can show signs of previous ischaemia but cannot diagnose stable angina in itself.

Myocardial perfusion scintigraphy (C) is used to evaluate the functionality of the heart and is reserved for later-line.

A resting transthoracic echocardiogram (D), although useful, will not diagnose stable angina in itself.

Question 57

A 70 year old man with a history of stable angina presents to his GP complaining of ongoing exertional chest pain despite taking regular bisoprolol. The GP wishes to add a further drug treatment.
Which would be the most appropriate drug to add to prevent this man’s angina attacks?

A. Nifedipine
B. Verapamil
C. Aspirin
D. Atorvastatin
E. Glyceryltrinitrate

Answer 57

A. First line treatment for angina is a beta-blocker, such as bisoprolol, or a cardioselective calcium channel blocker, such as verapamil or diltiazem. If these do not work by themselves, NICE recommend combining beta blockers with a non-cardioselective calcium channel blocker, such as nifedipine (A).

Combining a beta blocker with a cardioselective calcium channel blocker such as verapamil (B) is contraindicated due to a risk of asystole. Aspirin (C) is used to reduce the risk of myocardial infarctions as secondary prevention. Atorvastatin (D) is used to lower plasma cholesterol, not to prevent further angina attacks directly. GTN (E) is used for symptomatic treatment of stable angina attacks and does not prevent them.

Question 58

A 64 year old female with a background of stable angina and type 2 diabetes mellitus attends A+E. She has central, crushing chest pain radiating to the jaw that started approximately 90 minutes ago, not relieved by her glyceryl trinitrate spray. A 12-lead ECG is performed and shows ST segment elevation in leads II, III and aVF. She had aspirin in the ambulance and is currently receiving intravenous morphine and metoclopramide.
What is the most appropriate immediate management plan?

A. Fondaparinux, ticagrelor and fibrinolysis
B. Unfractionated heparin, prasugrel and percutaneous coronary intervention
C. Clopidogrel, atorvastatin, ramipril and bisoprolol
D. Fondaparinux and calculation of a GRACE score
E. Coronary artery bypass grafting

Answer 58

B. This patient is having a STEMI, and has presented within 12 hours. The most appropriate initial treatment here is dual antiplatelets (aspirin + prasugrel/ ticagrelor/ clopidogrel), alongside anticoagulation (unfractionated heparin) and PCI (B).

Fondaparinux, ticagrelor and fibrinolysis (A) are used if PCI cannot be done within 2 hours of presentation to hospital, but is not as good as (B).

(C) is the long-term drug management post-MI.

(D) describes the initial treatment for an NSTEMI or unstable angina.

CABG (E) is not typically performed for STEMIs and is used more for stable angina.

Question 59

A 72 year old female with a background of hypertension and a myocardial infarction 9 months ago presents to her GP with increasing shortness of breath. A subsequent transthoracic echocardiogram shows evidence of reduced left ventricular systolic function with normal right ventricular function.
Which of the following signs is this patient most likely to have?

A. Bilateral ankle oedema
B. Hepatomegaly
C. Raised jugular venous pressure
D. Bilateral crepitations at the lung bases
E. Ascites

Answer 59

D. This patient has left ventricular systolic failure. (D) is the only sign consistent with this, as fluid will back up from the poor left ventricle into the lungs.

The other signs (A, B, C, E) are all signs more typical of right ventricular failure as fluid backs up from the RV into the peripheries.

Question 60

An 80 year old male with a history of left-sided heart failure with reduced ejection fraction comes to see his GP complaining of ongoing shortness of breath on exertion. He currently takes furosemide, bisoprolol and ramipril.
Which treatment would be most appropriate for the GP to add next?

A. Sacubitril-valsartan
B. Spironolactone
C. Hydralazine and isosorbide mononitrate
D. Digoxin
E. Ivabradine

Answer 60

B. Spironolactone (B) is recommended as the next treatment to add after an ACE-I and beta blocker in heart failure with reduced ejection fraction and improves mortality.

The other drugs (A, C, D and E) can be added but are after spironolactone, normally by a specialist.

Question 61

26. A 40 year old man is noted to have a blood pressure of 160/110 mmHg at an appointment for his poorly-controlled Crohn’s disease. Ambulatory blood pressure monitoring subsequently arranged by his GP shows an average blood pressure of 163/117 mmHg. The patient mentions that he looks ‘bigger’ than normal and has noticed stretch marks on his abdomen, despite eating the same amount of food.
    What is the most likely cause for this man’s hypertension?

A. Essential hypertension
B. Conn’s syndrome
C. Cushing’s syndrome
D. Autosomal dominant polycystic kidney disease
E. Coarctation of the aorta

Answer 61

C. This question is asking about secondary causes of hypertension. He likely has Cushing’s syndrome (C) due to the clinical features - abdominal obesity and striae, and a history of poorly controlled IBD which has likely needed multiple courses of steroids.

Essential hypertension (A) is less common in someone this age. There is nothing in the history to suggest Conn’s syndrome (B), ADPKD (D) or coarctation of the aorta (E), although these are all causes of secondary hypertension.

Question 62

You are reviewing a 55 year old man with type two diabetes. He has had average ambulatory blood pressure readings over the last 2 weeks of 145/97 mmHg. You both agree that a drug treatment for his hypertension would be beneficial.
What is the most appropriate drug to start?

A. Indapamide
B. Amlodipine
C. Spironolactone
D. Bendroflumethiazide
E. Rampiril

Answer 62

E. NICE recommend that in people with type 2 diabetes of any age, an ACE-I (E) is first-line for hypertension.

Indapamide (A) is a thiazide-like diuretic, which can be added 2nd line.

Amlodipine (B) is a calcium channel blocker which can be used first-line in Afro-Carribean people or those aged 55+ who don’t have type 2 diabetes.

Spironolactone (C) is used later down the line if the above treatments have not worked.

Bendroflumethiazide (D) is a thiazide diuretic, not currently used for hypertension - only ‘thiazide-like’ diuretics are on the NICE pathway.

Question 63

A 70 year old man presents to the GP with shortness of breath on exertion. As part of the work-up, the GP auscultates the patient’s chest and notes an ejection systolic murmur radiating to the carotids.
What is the most likely cause of the murmur?

A. Senile calcification of the valve
B. Bicuspid valve
C. Rheumatic fever
D. Infective endocarditis
E. Carcinoid syndrome

Answer 63

A. He has an ejection systolic murmur radiating to the carotids and therefore probably has aortic stenosis. The most common cause of this is senile calcification of the valve (A).

A bicuspid aortic valve (B) is commoner in people under 60 years old.

Rheumatic fever (C) is rare in the West and there is nothing in the history to suggest this.

Aortic stenosis being caused by endocarditis (D) or carcinoid syndrome (E) is highly unlikely.

Question 64

You are the FY1 on call for medicine. You are asked to review a patient’s ECG and note a heart rate of approximately 120 beats per minute, with an irregularly irregular rhythm and a lack of P waves. An old ECG from a previous admission shows the same pattern. You see the patient has a history of a metallic aortic valve replacement.
What drug is the patient most likely taking to prevent a stroke?

A. Apixaban
B. Warfarin
C. Low molecular weight heparin
D. Aspirin
E. Clopidogrel

Answer 64

B. The ECG describes atrial fibrillation. Patients who warrant anticoagulation to prevent strokes are normally given a personal choice between a DOAC e.g. apixaban (A) or warfarin (B). Warfarin is correct here as the patient has a metal heart valve and DOACs are not as good as warfarin here.

LMWH (C) could be used in the short-term if someone needed anticoagulation acutely in hospital, but the patient’s old ECG shows AF.

Aspirin (D) and clopidogrel (E) are not used to prevent strokes in AF as the blood pooling in the atria has more venous properties, so anticoagulants are used rather than antiplatelets.

Question 65

A 32 year old female presents to A+E with central chest pain, that is worse lying flat. A 12-lead ECG shows PR depression and widespread ST segment elevation. She is otherwise well.
What is the most appropriate initial treatment for the most likely cause of the patient’s symptoms?

A. Paracetamol
B. Ibuprofen
C. Ibuprofenandcolchicine
D. Percutaneous coronary intervention
E. Prednisolone

Answer 65

C. The symptoms and ECG point to pericarditis. The treatment of this is NSAIDs and colchicine (C).

Paracetamol (A) would not be used to treat the pericarditis itself.

Ibuprofen alone (B) used to be used for pericarditis but the addition of colchicine is beneficial.

PCI (D) has no place here.

Steroids like prednisolone (E) can be used in pericarditis but normally only if there is an autoimmune cause as it can give people more recurrences.

Question 66

Name 3 clinical features needed for diagnosis of typical stable angina

Answer 66

Chest pain that radiates (1)
Relieved with rest or GTN spray (1)
Provoked by physical exertion (1)

Question 67

QRISK is a cardiovascular disease risk predictor used by GPs. Give 3 modifiable and 3 non- modifiable risk factors for cardiovascular disease that are asked for in a QRISK calculation?

Answer 67

Modifiable: Smoking, Diabetes, Cholesterol/HDL ratio, Blood Pressure, BMI

Non-Modifiable: Age, Gender, Ethnicity, Angina/MI 1st degree relative, Diagnosis of: AF, RA, SLE, ED, Sever mental illness,

Question 68

Give an example of an ACEi and a side effect of this drug?

Answer 68

Example: Ramipril, Lisinopril, Enalapril

SE: Dry Cough, Hyperkalaemia, Fatigue, Headache

Question 69

Patient arrives to hospital with a suspected MI. ECG shows ST elevation. What would you expect to see on the ECG over the next few hours and the next few days?

Answer 69

Hours = Tall T waves, ST Elevation.

Days = T inversion, Pathological Q waves

Question 70

What are the 3 cardinal symptoms of heart failure?

Answer 70

• Shortness of breath
• Fatigue
• Peripheral oedema

Question 71

You suspect that a patient has heart failure and perform a chest x-ray. Name 3 signs that you would be visible to confirm your diagnosis?

Answer 71

• Alveolar oedema (bat wings)
• Kerley B lines (interstitial oedema),
• Cardiomegaly,
• Dilated Prominent Upper Lobe Vessels,
• Pleural Effusion

Question 72

Name 2 of the 4 features of Tetralogy of Fallot.

Answer 72

• A large, misaligned ventricular septal defect
• An overriding aorta
• Right ventricular outflow tract obstruction
• Right ventricular hypertrophy

Question 73

What condition is characterised with a concave-upwards (saddle-shaped) ST
elevation on ECG?

Answer 73

Pericarditis

Question 74

What would be the first-line treatment for a 49-year-old Caribbean male with a BP of 148/96?

Answer 74

Calcium Channel Blocker (e.g. amlodipine)

Question 75

What is the most likely diagnosis of a patient with the following ECG findings? ECG: F waves, no P waves, QRS irregularly irregular?

Answer 75

Atrial fibrillation

Question 76

Name 2 clinical features of aortic dissection.

Answer 76

• Sudden ‘tearing’ chest pain +/- radiates to back
• Unequal arm pulses and BP
• Acute limb ischaemia
• Paraplegia
• Anuria

Question 77

What are the four stages of chronic limb ischaemia?

Answer 77

• Stage I: asymptomatic
• Stage II: intermittent claudication
• Stage III: rest pain/nocturnal pain
• Stage IV: necrosis/gangrene

Question 78

Give 2 causes of secondary hypertension?

Answer 78

Renal Disease e.g CKD, renal artery stenosis, polycystic kidney disease, Cushing’s,
Conn’s, Phaeochromocytoma, Coarctation of aorta, Pregnancy, COCP

Question 79

There are several types or causes of shock, circulatory failure that leads to
inadequate organ perfusion, give 3 examples.

Answer 79

Anaphylactic, Cardiogenic, Septic, Haemorrhagic, Neurogenic

Question 80

Give 2 complications of an aneurysms?

Answer 80

Rupture, Thrombosis, Embolism, Excess pressure on other structures

Question 81

A 64-year-old man presents to A & E with central chest pain that radiates to the left shoulder, nausea and sweating. He has no allergies and takes simvastatin for high cholesterol. You commence them on oxygen and administer morphine for pain relief. Your consultant asks you prescribe an appropriate antiplatelet therapy for the patient, what do you give?

A. Aspirin alone
B. Aspirin and Ticagrelor
C. Clopidogrel alone
D. Clopidogrel and Warfarin
E. Dalteparin

Answer 81

B – Aspirin and Ticagrelor
Patients with MI require dual antiplatelet therapy consisting of aspirin and a PY12 inhibitor (e.g clopidogrel, ticagrelor or prasugrel).

Note that warfarin (D) and dalteparin (E) are not antiplatelet therapies, they prevent venous clotting and hence are often prescribed in situations such as DVT, PE or AF. Acute Coronary Syndromes suggests immediate management of STEMI involves: use of GTN spray, administer O2 (only if hypoxaemic, pulmonary oedema or continuing myocardial ischaemia) analgesia- (e.g morphine and a co-prescribed antiemetic), dual antiplatelet therapy (aspirin and clopidogrel/ticagrelor), restore patency to occluded artery (PCI or thrombolytic drug).

Question 82

Which statement best describes the pharmacology of spironolactone?

A. Inhibition of aldosterone receptor in the distal tubules
B. Inhibition of cyclooxygenase enzymes in the proximal tubules
C. Inhibition of L-type voltage-gated calcium channels in the nephron
D. Inhibition of sodium chloride transporter in the distal convoluted tubule
E. Inhibition of sodium/potassium/chloride symporter in the loop of Henle

Answer 82

A – Inhibition of aldosterone receptor in the distal tubules

(B) inhibition of cyclooxygenase enzymes in proximal tubules= COX inhibitor e.g Aspirin.
(C) Inhibition of L-type voltage gated calcium channel in the nephron= calcium channel blocker e.g Amlodipine.
(D) inhibition of the sodium chloride transporter in the distal convoluted tubule= thiazide-like diuretic e.g Bendroflumethiazide.
(E)Inhibition of the sodium/potassium/chloride symporter in the loop of Henle= loop diuretics e.g furosemide.

Question 83

Which of the following is not an associated risk factor for hypertension?

A. Caucasian race
B. High caffeine consumption
C. Sedentary lifestyle
D. Smoking
E. Type A personality

Answer 83

A- Caucasian race

High caffeine consumption, sedentary lifestyle, smoking and type A personality are all associated with an increased risk of developing hypertension. Note that from the hypertension management guidelines afro-Caribbean race carries an increased risk of hypertension (<55/Afro-Caribbean = ACEi first line).

Question 84

A patient is referred to a cardiology clinic after presenting to their GP with shortness of breath after walking for 50 metres and general fatigue. on auscultation there is an audible pan-systolic murmur at the apex. What is the most likely diagnosis?

A. Aortic stenosis
B. Aortic regurgitation
C. Mitral stenosis
D. Mitral regurgitation
E. Tricuspid regurgitation

Answer 84

D – Mitral regurgitation

Aortic stenosis would present with syncope and angina, and on auscultation an ejection systolic murmur would be heard.
Aortic regurgitation would present with symptoms to similar symptoms as aortic stenosis, with an early diastolic/Austin Flint murmur heard on auscultation.
Mitral stenosis would present with similar symptoms to mitral regurgitation, but with a diastolic murmur on auscultation.
Tricuspid regurgitation may present with signs of right-sided heart failure, this pansystolic murmur is not heard at the apex but at the left lower sternal edge.

Question 85

Which of the following ECG changes is most typically seen in a patient with a myocardial infarction?

A. Absent P waves
B. QT prolongation
C. ST depression
D. Tall, tented T waves
E. Wide QRS complex

Answer 85

C – ST depression
Myocardial infarction ECG changes include: ST elevation, ST depression (C), T wave inversion, abnormal Q wave.

Absent P waves (A) are typically seen in SVT, atrial fibrillation, atrial flutter.
Tall tented T waves (D) are characteristic of hyperkalaemia.
QT prolongation (B) can be a side effect of medications e.g amiodarone and certain antibiotics.
(E) Wide QRS complexes are typically seen in patients with bundle branch blocks.

Question 86

John is a 53-year-old Caucasian gentleman who attended GP clinic 2 weeks ago for an annual check-up. In the GP practice his BP was recorded as 155/100mmHg and he was subsequently given given an ambulatory blood pressure monitor for 2 weeks. His results show an average blood pressure of 138/91mmHg. What is the most appropriate management for this result?

A. Amlodipine
B. Bendroflumethiazide
C. Lifestyle changes only
D. Losartan
E. Ramipril

Answer 86

E – Ramipril

A blood pressure over 135/85 recorded by ambulatory BP monitoring requires pharmacological management therefore (C) lifestyle changes only is incorrect.
John is caucassian and under 55 so first line is an ACE inhibitor such as ramipril (E).

If John was Afro- Caribbean or over 55 he would be started on a calcium channel blocker like amlodipine (A).

If John was intolerant to ramipril he could be started on an angiotensin receptor blocker such as losartan (D).

If John’s BP did not respond to treatment with an ACE inhibitor or ARB he could be started on a thiazide-like diuretic, for example Bendroflumethiazide (B).

Question 87

An 89-year-old patient with multiple undiagnosed cardiovascular co-morbidities is brought to A&E with slurred speech, left arm weakness and a severely ataxic gait. Which underlying condition is most likely to have contributed to this presentation?

A. Atrial fibrillation
B. Cor pulmonale
C. Infective endocarditis
D. Left bundle branch block
E. Myocardial infarction

Answer 87

A – Atrial fibrillation
This patient has the classical symptoms of a stroke. AF (A) increases the risk of stroke due to blood collecting in the atria and forming clots.

Cor pulmonale (B) is right sided heart failure and presents with shortness of breath.

Myocardial infarction (E) would most commonly present with symptoms like chest pain, nausea, and sweating.

Left bundle branch block (D) is normally asymptomatic and is diagnosed by ECG changes.

Infective endocarditis (C) can cause stroke however, it is much rarer than AF and you would expect other indications in the history of IE such as fever, new murmur, Janeway lesions, Osler’s nodes, splinter haemorrhages etc.

Question 88

Jane is a 68-year-old woman who has presented to her GP following a diagnosis of hypertension. She is worried that she is at increased risk of having a heart attack and wants to know how likely this is. Which framework should her GP use to calculate Jane’s risk?

A. ABCD2 score
B. CHA2DS2-VASc score
C. COVID19 score
D. QRISK2 score
E. Wells score

Answer 88

B – QRISK2 score
ABCD2 is used to determine stroke risk after a TIA.

CHA2DS2-VASc is used to calculate stroke risk in patients with AF.

COVID19 is not a score.

Wells score is used to determine the risk of DVT or PE (note, different wells scores respectively).

Question 89

Which of the following best describes the concept of relative risk in the context of a trial examining the efficacy of statins compared to placebo in reducing heart attacks?

A. The risk of a heart attack in the statin group was 1.65% compared to 2.67% in the placebo group, therefore statins decrease the risk of heart attack by 1.02%.
B. The risk of a heart attack in the statin group was 1.65% compared to 2.67% in the placebo group, therefore statins decrease the risk of heart attack by 61%.
C. 98 patients would need to be treated with statins to prevent 1 heart attack.
D. 98 patients would need to be treated with placebo to cause 1 heart attack.
E. If this study was conducted 100 times, these results would occur in 95 of the 100 times.

Answer 89

B

Statins reduce the risk of heart attack therefore it is to be expected that in the trial a smaller percentage of heart attacks to occur in the statin group compared to the placebo group.

(B) describes the relative risk reduction (1.65/2.67x100 =61.%)

whereas (A) describes the absolute risk reduction (2.67-1.65=1.02).

(C) is describing the number needed to treat (NNT) of statins.

D is describing the number needed to harm (NNH) of placebo.

E is describing the concept of a 95% confidence interval.

Question 90

Which of the following is the correct order for the electrical conduction of the heart?

A. AV node -> atria -> SA node -> bundle of His -> Purkinje fibres -> L and R bundle branches -> ventricles

B. SA node -> ventricle -> AV node -> bundle of His -> Purkinje fibres -> L and R bundle branches -> atria

C. bundle of His -> Purkinje fibres -> atria -> AV node -> L and R bundle branches -> ventricles→SA node

D. SA node -> atria -> AV node -> bundle of His -> Purkinje fibres -> L and R bundle branches -> ventricles

E. SA node -> atria -> AV node -> L and R bundle branches -> Purkinje fibres -> bundle of His -> ventricles

Answer 90

D correctly describes the route of electrical conduction through the heart.

Question 91

Which parameter isn’t in the scoring system used to calculate the stroke risk in patients with Atrial Fibrillation?

A. Age
B. Blood Pressure
C. Congestive Heart Failure
D. Diabetes
E. Family History

Answer 91

E- Family History

The CHADS VASc score is used to calculate the stroke risk and subsequently anticoagulation need in patients with Atrial Fibrillation.
CHADS-VASc stands for
Congestive Heart Failure // Hypertension // Age (75+=2) // Diabetes
Stroke/ TIA/ Thromboembolism
Vascular disease // Age (65-74) // Sex category (female=1)

Question 92

Which of the following pulses is associated with Atrial Fibrillation?

A. Absent
B. Collapsing
C. Irregularly irregular
D. Pulsus paradoxus
E. Radio-Radial delay

Answer 92

C- Irregularly Irregular

(A)Absent= asystole/death
(B)Collapsing= aortic regurgitation,
(C) Irregularly irregular= atrial fibrillation.
(D) Pulsus paradox= BP drops significantly during inspiration, seen in severe Asthma, COPD, blood loss and cardiac conditions.
(E) Radio-radial delay= pulse is significantly stronger in one arm than the other and is seen in coarctation of the aorta.

Question 93

An ejection crescendo-decrescendo systolic murmur would be suggestive of which valvular pathology?

A. Aortic regurgitation
B. Aortic stenosis
C. Mitral regurgitation
D. Mitral stenosis
E. Pulmonary stenosis

Answer 93

B- Aortic Stenosis is the correct answer as it produces an ejection systolic crescendo decrescendo murmur (and a slow rising, narrow pulse pressure), heard loudest on expiration.

(A)Aortic regurgitation produces an early diastolic decrescendo murmur (and a collapsing pulse)
(C) Mitral regurgitation produces an apical pansystolic murmur.
(D) Mitral stenosis produces an apical mid diastolic rumble.
(E) Pulmonary stenosis produces an ejection systolic murmur heard loudest on inspiration.

Question 94

What are the three cardinal signs of heart failure?

A. Angina, shortness of breath, oedema
B. Cough, ankle oedema, fatigue
C. Headache, fatigue, shortness of breath
D. Pallor, ankle oedema, headache
E. Shortness of breath, fatigue, ankle oedema

Answer 94

E- Shortness of breath, fatigue, ankle oedema

The three cardinal signs of heart failure are shortness of breath, fatigue and ankle oedema. Patients often experience orthopnoea (dyspnoea when lying flat) and also paroxysmal episodic nocturnal breathing (stopping breathing in your sleep).
Other signs include cold peripheries, raised JVP, hypotension, cyanosis, oedema and increased weight.
On examination patients can have 3rd and 4th heart sounds, displaced apex beat, murmurs and bibasal crackles.

Question 95

A 56-year-old Asian man has come into your GP surgery, he has tried to modify his diet, exercise more and improve other lifestyle factors. He wishes to be put onto a tablet and his ambulatory blood pressure reading was 155/100. What would you advise?

A. Amlodipine prescription
B. Candesartan prescription
C. Further lifestyle measures are recommended
D. He should return for a health check once he turns 60
E. Ramipril prescription

Answer 95

A - Amlodipine prescription
The first line treatment for a patient with hypertension who is over 55 or is of afrocarribean descent is a calcium channel blocker. Amlodipine is an example of this. If the man was under 55, he should be considered for an ACE inhibitor such as ramipril or an ARB (angiotensin receptor blocker) such as Candesartan.

Question 96

Which of the following signs on ECG would be most indicative of a diagnosis of Right Bundle Branch Block?

A. R wave in V1, and Slurred S wave in V1
B. R wave in V1 and Slurred S wave in V6
C. R wave in V6 and Slurred S wave in V1
D. R wave in V6 and Slurred S wave in V6
E. Wide QRS and abnormal pattern.

Answer 96

B- R wave in V1 and Slurred S wave in V6
R wave resembles an M // Slurred S wave resembled a W.
Use the acronyms MARROW and WILLIAM to help you remember which is which.

• MARROW ‘RR’= Right bundle branch block. The first letter is M so lead 1 has a complex
  resembling an M (R wave) and the 6th letter is W so lead 6 has a complex resembling a W (Slurred
  S wave).
• WILLIAM ‘LL’= Left Bundle Branch Block. The first letter is W so lead 1 has a complex resembling
  a W (Slurred S wave) and as the 6th letter is M lead 6 has a complex resembling an M (R wave).
  This is the opposite of RBBB.

Question 97

Which of the following isn’t a sign of critical ischaemia?

A. Pain
B. Paralysis
C. Paraesthesia
D. Perishingly cold
E. Pink

Answer 97

E- Pink
The ‘6 Ps of critical limb ischaemia’ are: Pain, Pallor, Paralysis, Paralysis, Paraesthesia, Perishingly cold and pulselessness. The limb would be pale not pink.

Question 98

Which of these isn’t a feature of tetralogy of Fallot?

A. Atrial septal defect
B. Hypertrophy of the right ventricle
C. Overriding aorta
D. Pulmonary stenosis
E. Ventricular septal defect

Answer 98

A- Atrial Septal Defect
The 4 key features of tetralogy of fallow are ventricular septal defect, pulmonary stenosis, hypertrophy of the right ventricle and overriding aorta.

I find it helpful to think of the VSD overloading the already narrow/stenosed pulmonary outflow track and this is why you get the hypertrophy of the right ventricle.

Question 99

Which blood pressure reading taken in clinic would be classed as stage 1 hypertension?

A. 125/80
B. 135/85
C. 145/95
D. 165/105
E. 180/110

Answer 99

C- 145/95
Clinic Readings:
Stage 1= >140/90.
Stage 2= >160/100.
Severe HTN= >180/110

Ambulatory readings (C) 145/95= Stage 1 HTN.
(D) 165/105 =Stage 2 HTN.
(E) 180/110= Severe HTN

Question 100

Which of the following is not a sign of infective endocarditis?

A. Janeway lesions
B. Osler’s nodes
C. Roth spots
D. Splinter haemorrhages
E. Xanthelasma

Answer 100

E- Xanthelasma are cholesterol deposits around the eyes.

Distinctive signs of infective endocarditis are splinter haemorrhages, Osler’s nodes, Janeway lesions, Roth spots and fever.

Question 101

George, a 55-year-old male, is brought to A&E via ambulance 4 hours after experiencing severe central crushing chest pain sweating and vomiting. The ECG performed by the paramedics shows ST segment elevation in Leads V1-V6. His observations show a raised HR and RR, O2 sats 97% OA, he is afebrile. Which of the following is the most appropriate management for the patient?

A. CT Pulmonary Angiogram
B. Fibrinolysis with IV Tenecteplase
C. High flow oxygen
D. Percutaneous Coronary Intervention
E. Prophylactic broad spectrum antibiotics

Answer 101

(B)- Fibrinolysis with IV Tenecteplase performed within 12 hours of STEMI onset if patients cannot get PCI done (PCI must be done within 2 hours of onset and our patient presents to A&E after 4 hours)

(A)- CTPA is diagnostic investigation for suspected PE, performed in patients with Wells Score>4.
(C)- High flow oxygen is only indicated in patients with STEMI that are hypoxic, our patient has sats of 97% OA.
(D)- PCI is first line treatment for STEMI if it can be performed within 2 hours of onset, otherwise it is fibrinolysis with IV Tenecteplase
(E)- The patients observations show they are afebrile, infective cause is unlikely in this scenario and hence broad-spectrum antibiotics are not indicated.

Question 102

A 74-year-old female attends General Practice complaining of no longer being able to get comfy in bed. For the past 2 months she has noticed she needs more and more pillows under her head and often wakes up in the middle of the night ‘gasping for breath’. On examination, you notice bilateral oedematous legs. Which of the following is the most appropriate first line investigation?

A. Chest X-ray.
B. CT chest.
C. NT-proBNP (BNP) levels.
D. ECG.
E. Echocardiogram.

Answer 102

C- NT-proBNP (BNP) levels. NICE guidelines recommend NT-proBNP for diagnosing heart failure.

(A) CXR shows signs of heart failure (ABCDE) but is not diagnostic and not first line
(B) CT scan wouldn’t be first line investigation for heart failure.
(D) ECG can show changes but not diagnostic.
(E) Echocardiogram is gold standard but not a first line investigation.

Question 103

A 54-year-old white male attends General Practice after undergoing ambulatory blood pressure monitoring (ABPM). His average reading was 138/90mmHg. You give relevant lifestyle advice and he re-attends 1 month later with an ABPM of 142/94mmHg. What is the most appropriate management for this patient?

A. Bisoprolol.
B. Furosemide.
C. Ramipril.
D. Amlodipine.
E. Nifedipine.

Answer 103

C- Ramipril - ACEi is first line treatment based on this patients’ demographics.
This patient has stage 1 hypertension. (stage 1. ≥140/90 mm Hg, stage 2. ≥160/100, stage 3. ≥180 systolic or 120 diastolic.)

(A) Bisoprolol is a beta-blocker, a rate limiting drug not used as first line treatment for HTN.
(B) Furosemide is a loop diuretic not used for the treatment of HTN, thiazide like diuretics such as
Bendroflumethiazide are second line options.
(D) Amlodipine is a dihydropyridine calcium-channel blocker first line for >55yrs or of Afro-Caribbean
ethnicity.
(E) Nifedipine is a dihydropyridine calcium-channel blocker first line for >55yrs or of Afro-Caribbean
ethnicity.

Question 104

A 63-year-old female presents to the General Practice complaining of chest pain, shortness of breath and a single episode of fainting this week. On examination, the GP hears an ejection systolic murmur, loudest at the 2nd intercostal space, right sternal edge. What is the most likely underlying cause of this murmur?

A. Heart failure.
B. Aortic regurgitation.
C. Mitral regurgitation.
D. Mitral stenosis.
E. Aortic stenosis.

Answer 104

E- Aortic Stenosis - An ejection-systolic murmur is characteristic for aortic stenosis.

(A) Patients with HF will only present with a murmur if there is also valvular disease, however there can be a gallop rhythm due to the presence of S3.
(B) An early diastolic murmur is characteristic for aortic regurgitation
(C) A pansystolic murmur is characteristic for mitral regurgitation.
(D) A rumbling mid-diastolic murmur is characteristic for mitral stenosis.

Question 105

A 62-year-old male attends his General Practice complaining on worsening dyspnoea. He has a past medical history of heart failure. The GP wants to investigate him further and orders a chest x-ray. Which of the following is not a sign associated with heart failure on chest x-ray?

A. Interstitial oedema
B. Cardiomegaly
C. Dilated bronchioles
D. Prominent upper lobe vessels.
E. Pleural effusion.

Answer 105

C- Dilated Bronchioles

Chest Xray signs for heart failure are ABCDE (Alveolar oedema, Kerley B lines (interstitial oedema), Cardiomegaly, Dilated upper lobe vessels, pleural Effusion). Therefore C- dilated bronchioles is incorrect.

Question 106

A 55-year-old male is invited by his local practice to undergo an NHS health check. During the check the healthcare professional uses a risk calculator in order to determine his 10– year probability of suffering from a cardiovascular event. What is the name of this risk calculator?

A. CHA2DS2–VaSc
B. QRisk3
C. ABCD2
D. Wells’ score
E. Modified Duke Criteria

Answer 106

B- QRisk3= 10-year probability of CV event.

(A) Cha2Ds2-VaSc= risk of stroke in AF.
(C) ABCD2= risk of stroke after TIA.
(D) Wells score= risk of DVT.
(E) Modified Duke Criteria= Infective endocarditis criteria.

Question 107

A 50-year-old female attends General Practice complaining of a dry cough. She mentions it has only started recently. Past medical history includes: Asthma (1985), Diabetes (2015), Hypertension (2020). Her medications include salbutamol inhaler, metformin 500mg OD, ramipril 2.5mg OD. All observations and examinations are normal. What is the most likely cause of this patient’s cough?

A. Infective exacerbation of asthma
B. Lung cancer
C. Pneumonia
D. Ramipril
E. Metformin

Answer 107

D- Ramipril

Most common side of effect of ACEi (ramipril) is a dry cough due to increased levels of bradykinin. It is unlikely to be infective exacerbation of asthma / pneumonia given all observations and examinations are normal- these cases would likely be abnormal; you would expect at least patient to be pyrexical. Unlikely to be lung cancer due to lack of other symptoms (weight loss, SOB etc). Metformin does not cause dry cough.

Question 108

A 67-year-old male is referred to a cardiologist due to detection of a new pansystolic murmur on examination. The cardiologist suspects a diagnosis of mitral regurgitation. What is the most appropriate investigation to confirm the diagnosis?

A. Echocardiogram
B. ECG
C. Troponin-T
D. NT-proBNP (BNP) levels
E. Chest X-ray

Answer 108

A- Echocardiogram is the gold standard for diagnosing valvular disease.

(B) ECG may show arrhythmias but not diagnostic.
(C) Troponin- T I used to aid diagnosis of Acute Coronary Syndromes (ACS).
(D) NT-proBNP levels used to diagnose heart failure.
(E) CXR doesn’t diagnose valvular disease but may show LA enlargement.

Question 109

A 43-year-old female attends A&E complaining of palpitations, shortness of breath and dizziness. On examination the pulse rate is 134bpm and feels irregular. You suspect a diagnosis of atrial fibrillation and request an ECG to confirm this. Which of the following ECG changes is associated with atrial fibrillation?

A. Sawtooth flutter waves
B. Absent P waves
C. Delta waves
D. Saddle-shaped ST segment elevation
E. ST segment depression

Answer 109

B- Absent P waves, narrow QRS + irregularly irregular ventricular rhythm are all ECG changes
associated with AF.

(A) Sawtooth flutter waves= seen in atrial flutter.
(C) Delta waves= Wolff-Parkinson-White syndrome.
(D) Saddle-shaped ST segment elevation= acute pericarditis.
(E) ST segment depression= sometimes seen in myocardial ischaemia.

Question 110

A 19-year-old male collapses whilst playing a football match for his local team. Paramedics arrive rapidly and find him in cardiac arrest and attempt to defibrillate him. His brother who was playing football with him tells you that he’s normally fit and well but for the past few months he had been experiencing some chest pain, palpitations and unexplained syncope. His brother also mentions that their dad died at a young age due to “some heart problems”. What is the most likely cause of this patient’s cardiac arrest?

A. Atrial fibrillation.
B. Aortic stenosis.
C. ST elevation myocardial infarction (STEMI).
D. Non-ST elevation myocardial infarction (NSTEMI).
E. Hypertrophic cardiomyopathy.

Answer 110

E- Hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy is most likely given that he’s young and has a +ve family history of young cardiac death. Other diagnoses are unlikely due to his young age.

Question 111

A 58-year-old Afro-Caribbean male is known to have essential hypertension, he has been on Amlodipine for 3 months, but his blood pressure remains at 145/95, what is the next appropriate step in managing this patient’s hypertension?

A. Percutaneous Coronary Intervention
B. Prescribe Atenolol
C. Prescribe Candesartan and withdraw Amlodipine
D. Prescribe Bendroflumethiazide in addition to Amlodipine
E. Prescribe Rampiril in addition to Amlodipine

Answer 111

E- Prescribe Ramipril in addition to Amlodipine

Hypertension management: patients under 55 should be started on ACEi/ARB, patients over 55 (like in this case- age 58) or afrocarribbean should be started on CCB. If hypertension persists then the 2nd line treatment is to combine the ACEi/ARB and the CCB. If hypertension persists add Thiazide-like diuretic. Therefore answer is (E) prescribe ramipril in addition to amlodipine.

Percutaneous Coronary Intervention (A) is used for the management of MI not HTN.
Atenolol (B) is a beta blocker, rate-control drug with limited use in HTN management. Adding Candesartan and removing amlodipine is not appropriate as we need to combine ACEi/ARB and CCB for 2nd line not switch to the other.
Prescribing Bendroflumethiazide (D) is the third line management not 2nd.
ACEi example= Ramipril. ARB example= Candesartan. CCB example= Amlodipine. Thiazide-like diuretic example= Bendroflumethiazide.

Question 112

Jim, a 20-year-old male, with known type 1 diabetes presents to A&E with abdominal pain and increased thirst. He is breathing deeply and quickly and there is a smell of ‘pear-drops’ on his breath. He tells you he ran out of insulin 3 days ago and hasn’t had chance to go to the GP to collect some more. His ABG shows a metabolic acidosis and his blood glucose is significantly raised. Which of the following is least likely to be seen on Jim’s ECG?

A. Absent P waves
B. Long PR interval
C. Wide QRS complex
D. Tall Tented T waves
E. U waves

Answer 112

E- U waves

The presentation described Diabetic Ketoacidosis- patient with known T1DM with missed doses of insulin. Insulin normally transports glucose and potassium into cells therefore a lack of insulin causes hyperglycaemia and hyperkalaemia. As a result of the lack of glucose in cells the body starts to break down fat causing an increase in ketones. Ketones are acidic and hence cause metabolic acidosis, they can be smelt on patients breath as a sweet ‘pear-drop’ smell. Patients in DKA often take deep, fast breaths called Kusmall breaths- this is an attempt to ‘blow off’ CO2 to try and reverse the acidosis. It is important to recognise the ECG signs of hyperkalaemia as it can cause arrhythmias and subsequent death. Hyperkalaemia= Absent P, Long PR interval, Wide QRS, Tall Tented T waves (Go, Go long, Go wide, Go tall= Gonner). Hypokalaemia= U wave

Question 113

Which of the following is a type of cardiomyopathy?

A. Vasoconstricted
B. Infective
C. Idiopathic
D. Dilated
E. Congenital

Answer 113

D- Dilated
Cardiomyopathy types: dilated, restrictive, hypertrophic. Cardiomyopathy is generally congenital and can also be idiopathic.

Answers A,B,C,E are not types of cardiomyopathy, they are ways of describing potential ways in which cardiomyopathy may be acquired.

Question 114

Earlier today Betty, a 67-year-old lady, had a fall. She was sitting in her chair for most of the morning but on standing up she immediately collapsed to the floor. She did not lose consciousness but did hit her head. She is brought to A&E where a reassuring CT scan shows no abnormalities or bleed. You perform a lying and standing blood pressure, diagnose postural hypotension and appropriately reduce some of her anti-hypertensive medications. Which of the following BP results reflect those recorded in Bettys notes?

A. Lying 118/82, standing 138/98
B. Lying 120/110, standing 107/93
C. Lying 137/103, standing 109/88
D. Lying 147/99, standing 137/96
E. Lying 150/102, standing 140/9

Answer 114

C- Lying 137/103, standing 109/88
Postural hypotension- 137/103 to 109/88 because 137-109= drop of 28mmHg.

(A) Normal lying and standing BP response- 118/82 then increased to 138/90
(B) Narrow pulse pressure- 120/110 seen in aortic stenosis
(D) Stage 1 hypertension- 147/99 (BP>140/90= stage 1)
(E) Wide pulse pressure- 150/102 seen in aortic regurgitation

Question 115

Tony, a 45-year-old male presents to A&E with central chest pain that radiates to his jaw and arm. Which of the following aspects elicited from Tony’s history is most relevant in diagnosing his condition?

A. His grandad had a myocardial infarction when they were 80
B. He smoke 20 cigarettes a day and has done for the last 10 years
C. He had surgery for a fractured femur when he was 36
D. He has a family history of Thyroid disorders
E. He is allergic to penicillin

Answer 115

B- Smoke 20 cigarettes a day and has done for the last 10 years - Smoking is relevant as it is a significant risk factor for MI, his 10 year pack history is likely to play a role in his current presentation.

(A) Cardiac family history is only applicable if it occurred before the age of 55.
(C) Is irrelevant to his current presentation of chest pain given it was decades ago.
(D) Thyroid disorders are also important when taking a history but out of the answers smoking is most relevant to the type of symptoms.
(E) An allergy to penicillin is also very important, but the question asks specifically about making a diagnosis.

Question 116

Which of the following signs is most likely to indicate that a patient is in septic shock?

A. Apyrexial
B. Bradycardia
C. Bounding Pulse
D. Reduced airway entry
E. Paraesthesia

Answer 116

C- Bounding Pulse

(A)- septic shock is caused by wide-spread infection in the blood therefore the patient will be pyrexic.
(B)- bradycardia -a classical sign of cardiogenic shock- septic shock most likely to be tachycardic.
(D)- reduced airway entry- anaphylactic shock because of swelling of the airways.
(E) Paraesthesia isn’t a common feature of any type of shock. Therefore, the answer is C- bounding pulse.

Question 117

Which of the following is least likely to cause hypovolaemic shock?

A. Gastrointestinal Bleed
B. Severe Diarrhoea and Vomiting Secondary to Gastroenteritis
C. A 3rd degree burn to the torso
D. Pancreatitis
E. Pulmonary Embolism

Answer 117

E- Pulmonary Embolism.
PE does not cause any form of fluid/blood loss.
Hypovolemic shock is caused by blood/ fluid loss.

(A) GI bleeding causes loss of blood.
(B) severe diarrhoea/vomiting would cause loss of fluid.
(C) burns cause loss of fluid.
(D) pancreatitis is a known cause of hypovolaemic shock.

Question 118

A 70-year-old male presents to A&E with a pain that he describes as ‘tearing into his back’. He has a past medical history of acute coronary syndrome and recently suffered a 2nd NSTEMI. Which of the following is the most likely diagnosis for the patient?

A. Aortic Dissection
B. Myocardial Infarction
C. Cardiac Tamponade
D. Pulmonary embolism
E. Infective Exacerbation of COPD

Answer 118

A- Aortic Dissection
Aortic dissection typically is described as having a ‘tearing/shearing’ pain which goes to the back. Note that this can also be a symptom described in aortic aneurysm rupture- a medical emergency.

(B) MI typically presents with central crushing chest pain.
(C) Cardiac tamponade is caused by build up of fluid in the pericardial cavity but does not typically cause pain.
(D) pulmonary embolism presents with pleuritic chest pain, SOB and haemoptysis.
(E) infective exacerbation of COPD would likely present with respiratory symptoms such as SOB and productive cough.

Question 119

Which of the following is a symptom most reflective of Pericarditis?

A. ‘Crushing’ chest pain
B. Epigastric pain that radiates to the back
C. Pleuritic, sharp chest pain
D. Generalised sharp chest pain
E. Haemoptysis

Answer 119

C- pleuritic chest pain
Pericarditis presents with pleuritic, sharp chest pain which classically is worse on lying down and relieved by leaning forwards.

(A) is typical of MI.
(B) is typical of acute pancreatitis.
(E) haemoptysis is generally respiratory e.g TB, lung CA, PE.

Question 120

An 84-year-old lady is rushed into A&E with sudden onset epigastric pain which radiates to the back. Vital signs: HR: 112, BP: 92/63, RR: 36, O2: 89%, Temperature: 37C. Her hands are cold and clammy. What investigation is it important to do first?

A. Chest Xray
B. Coagulation screen
C. MRI
D. Troponin I
E. Ultrasound scan

Answer 120

E- Ultrasound Scan
From the history of sudden onset epigastric pain and her vital signs indicating shock one diagnosis to work to exclude is a ruptured abdominal aortic aneurysm (AAA). This is done by performing a rapid USS of the aorta, if confirmed it requires immediate surgical repair.

Question 121

Cecilia, a 45-year-old lady, attends a GP appointment complaining of feeling her heart skip a beat. She says it is particularly noticeable when she exercises and sometimes feels dizzy. Examination is unremarkable. Pulse is regular HR 75, no abnormal heart sounds heard on auscultation. The GP performs an ECG and suspects Wolff-Parkinson-White syndrome. If their suspicions are correct what should the ECG show?

A. Wide QRS, short PR, delta wave
B. Wide QRS, long PR, delta wave
C. Narrow QRS, long PR, delta wave
D. Narrow QRS, short PR, delta wave
E. Dropped QRS, progressively lengthened PR, delta wave

Answer 121

A- Wide QRS, short PR, delta wave

Wolf-Parkinson-white syndrome is a type of supraventricular tachycardia (SVT) caused when by an accessory pathway causing a re-entrant loop. The ECG findings are a wide QRS, short PR and a classical delta wave (slurred upstroke to the QRS).

Question 122

What type of arrhythmia is Wolff-Parkinson-White syndrome?

A. Atrioventricular re-entry tachycardia
B. Atrioventricular nodal re-entry tachycardia
C. Narrow complex tachycardia
D. Broad complex tachycardia
E. Ventricular tachycardia

Answer 122

A - Atrioventricular re-entry tachycardia
AVRT is when re-entry point is an accessory pathway (e.g. in WPW)

Supraventricular tachycardias are caused by the electrical signal of depolarisation re-entering the atria from the ventricles.
atrioventricular nodal re-entrant tachycardia is when re-entry point is back through atrioventricular node

Atrial tachycardia is where electrical signal originates in atria somewhere other than sinoatrial node (not technically caused by re-entering from ventricles but instead abnormally generated electrical activity in atria).

Question 123

What is the normal length of the PR interval on an ECG?

A. 0.012s – 0.020s
B. 0.08- 0.12s
C. 0.12- 0.20s
D. 0.38- 0.42s
E. 0.42- 0.48s

Answer 123

D- 0.12-0.20s
The limits of normal for a P-R interval are 0.12-0.20s. PR changes: Prolonged PR interval is found in heart block, shortened PR interval found in WPW, PR depression found in pericarditis.

0.08-0.12s (B) is the normal range for QRS. Wide QRS found in R/L bundle branch block, hyperkalaemia, WPW, ventricular rhythm, tricyclic antidepressant poisoning.

0.40-0.44s (D) is the normal range for QTc.

Question 124

A patient has been admitted to hospital with fast AF. Before the patient is discharged, she needs to be considered for oral anticoagulation therapy. Which of the following risk assessment tools is used to determine their risk of major haemorrhage?

A. CHA2DS2-VASc
B. HASBLED
C. ABCD2
D. Wells
E. Q RISK

Answer 124

B- HASBLED
HASBLED is used to calculate risk of bleeding for patients on anticoagulants.

(A)CHaDS2VaSc is used to determine likelihood of stroke in patients with AF.
ABCD2 (C) is used to calculate the risk of stroke following suspected TIA.
Wells (D) is used to calculate risk of DVT or PE- note there are 2 different risk scores depending on which one.
QRisk (E) is used to calculate the risk of a cardiovascular event in next 10 years. Useful tip- download MedCalc app for all risk scores.

Question 125

Usman, a 78-year-old gentleman, attends the GP complaining of increasing shortness of breath especially at night. He is using 3 pillows to sleep with and has noticed his legs are swollen. He has a past medical history of hypertension, GORD and a myocardial infarction. On examination you hear an S3 gallop and some bibasal crackles in the lung bases. Given the likely diagnosis, which of the following signs are least likely to be seen on chest x-ray?

A. Kerley B lines
B. Cardiothoracic ratio <0.5
C. Pleural effusion
D. Alveolar oedema
E. Dilated upper lobe vessels

Answer 125

B- Cardiothoracic ratio <0.5
Patients in HF have ABCDE signs on CXR.

A-alveolar oedema,
B- Kerley B lines,
C-cardiomegaly,
D- dilated pulmonary vessels-
E-pleural effusion.

In normal patients the heart should take up <50% of the thoracic width, if it takes up >50% then this is cardiomegaly. Hence the correct answer here is B- in heart failure the cardiothoracic ration would be greater than 0.5 not less than.

Question 126

What is the appropriate first line medication to treat a patient with heart failure?

A. Ace inhibitor + digoxin
B. B blocker + loop diuretic
C. B blocker + digoxin
D. B blocker + ace inhibitor
E. Loop diuretic + digoxin

Answer 126

D- B blocker and ACEi

ACE- and B blockers are proven to improve prognosis in heart failure. Diuretics are useful in that they provide symptomatic relief but do not improve survival. Always important to start low, titrate slowly and start the ace and b blocker at different times.

Question 127

Furosemide is often prescribed for patients who are fluid overloaded. Where in the kidney does this drug act?

A. Ascending loop of Henle
B. Collecting ducts
C. Distal convoluted tubule
D. Descending loop of Henle
E. Foot processes

Answer 127

A- Ascending loop of Henle

Furosemide is a loop direct that inhibits the Na+/K+/2Cl- cotransporter channel on the ascending limb of the loop of Henle.

Potassium-sparing diuretics e.g. amiloride act on distal convoluted tubule (C) inhibiting ENaC channels.

Thiazide-like diuretics e.g. Bendroflumethiazide inhibit Na+Cl- cotransporter channels in the distal convoluted tubule (C).

Question 128

Mohit, a 55-year-old man from Rotherham, is brought to NGH A+E with a 4-hour history of central crushing chest pain which radiates to his jaw which has not responded to his GTN spray. He is sweaty, tachycardic and vomiting. He has a past medical history of hypertension, type 2 diabetes and angina. A 12-lead ECG shows ST elevation in leads V1-V6 aVL and I. Which cardiac territory or territories have been affected?

A. Anterolateral
B. Inferior
C. Inferolateral
D. Lateral
E. Septal

Answer 128

A- Anterolateral

Question 129

Two days following an admission with STEMI a patient on the cardiology ward complains of acute breathlessness. A pansystolic murmur is noted on examination and heard loudest at the apex. What has happened to the patient?

A. Acute heart failure secondary to aortic stenosis
B. Acute heart failure secondary to mitral stenosis
C. Pulmonary oedema secondary to aortic regurgitation
D. Pulmonary oedema secondary to mitral regurgitation
E. They are having another ACS

Answer 129

D- Pulmonary oedema secondary to mitral regurgitation

Acute mitral regurg following MI occurs when territories suppling the papillary muscle or septum are affected causing them to rupture leading to valve incompetence. The murmur associated with mitral regurg is pansystolic- this is heard at the apex and may radiate to the axilla. Acute and severe mitral regurg can cause acute pulmonary oedema leading to breathlessness.

Other complications of MI are remembered by mnemonic DARTH VADER- Death, Arrhythmias, Rupture (ventricular septum/papillary muscles), Tamponade, Heart failure (acute/chronic), Valve disease, Aneurysm of ventricle, Dressler’s syndrome, thromboEmbolism, Recurrence/mitral Regurg.

Question 130

Managing heart attacks involves the use of dual antiplatelet therapy for example giving both aspirin and clopidogrel. What is the correct method of action of clopidogrel?

A. COX inhibitor
B. HMG coA reductase inhibitor
C. P2Y12 inhibitor
D. Phosphodiesterase 5 inhibitor
E. Vitamin K antagonist

Answer 130

C - P2Y12 inhibitor
Clopidogrel is an antiplatelet that prevents platelet aggregation by binding the P2Y12 receptor.

COX inhibitors (A) are NSAIDS.
HMG coA reductase inhibitors (B) are statins,
Phosphodiesterase 5 inhibitors (D) are sildenafil,
Vitamin K antagonists (E) are warfarin.