Cardiovascular Flashcards
A 65-year-old man presents with central crushing chest pain for the first time. He
is transferred immediately to the closest cardiac unit to undergo a primary
percutaneous coronary intervention. There is thrombosis of the left circumflex
artery only. Angioplasty is carried out and a drug-eluding stent is inserted. What
are the most likely changes to have occurred on ECG during admission?
A. ST depression in leads V1–4
B. ST elevation in leads V1–6
C. ST depression in leads II, III and AVF
D. ST elevation in leads V5–6
E. ST elevation in leads II, III and AVF
D. ST elevation in leads V5–6
Given the presentation here it is clear that this patient has suffered a complete infarction of the myocardium, this equates to ST elevation on ECG. It then comes down to knowing the ECG correlates with vascular territory.
Leads V1 and V2 indicate anterior (diagonal branch of LAD)
V3 and V4 is septal (septal branch of LAD)
V5 and V6 is lateral (as in this case) (left circumflex)
II, III, and AvF indicate inferior. (Posterior descending branch)
Putting this together we see that option (A) would be an anterio-septal infarct, the LAD artery.The depression on ECG would indicate a ischaemia not an infarct and PCI would be performed within 48hrs.
Option (B) would be the entire left ventricle and would be seen in left main stem occlusion.
(C) would be another PCI within 48 hrs, the affected territiory being inferior, and so the right posterior descending branch.
(E) would be an infarct in the same territory as (C)
A 78-year-old woman is admitted with heart failure. The underlying cause is
determined to be aortic stenosis. Which sign is most likely to be present?
A. Pleural effusion on chest x-ray
B. Raised jugular venous pressure (JVP)
C. Bilateral pedal oedema
D. Bibasal crepitations
E. Atrial fibrillation
D. Bibasal crepitations
A patient is admitted with pneumonia. A murmur is heard on examination. What
finding points to mitral regurgitation?
A. Murmur louder on inspiration
B. Murmur louder with patient in left lateral position
C. Murmur louder over the right 2nd intercostal space midclavicular line
D. Corrigan’s sign
E. Narrow pulse pressure
B. Murmur louder with patient in left lateral position
Any murmur that is louder on inspiration (A) is a right sided murmer (remembered by there being an ‘I’ in both right and inspiration.
The right 2nd intercostal space (C) is the anatomical landmark for the aortic valve, not the mitral. A murmur over the apex that is louder when laying on the left side is associated with mitral lesions (B) and is the correct answer here. If it is heard it should be established if the murmur radiates to the axilla.
Corrigan’s sign (D) is visibly exaggerated pulsing carotids is a sign of hyperdynamic circulation such as aortic regurgitation, as well as other signs; de Mussets, Traubes, Quinkes, Duroziez, amoungst others.
A narrow pulse pressure (E) is a sign of aortic stenosis.
A 79-year-old woman is admitted to the coronary care unit (CCU) with unstable
angina. She is started on appropriate medication to reduce her cardiac risk. She is
hypertensive, fasting glucose is normal and cholesterol is 5.2. She is found to be in
atrial fibrillation. What is the most appropriate treatment?
A. Aspirin and clopidogrel
B. Digoxin
C. Cardioversion
D. Aspirin alone
E. Warfarin
E. Warfarin
This patient should have thier cardiovascular risk factors controlled with best medical therapy (her hypertension and hypercholestreamia). There is no indication that this is an acute arrhythmia so cardioversion (C) is not indicated. She should be rate-controlled, but beta blockers would be more appropriate than digoxin (B) due to her ischaemic heart disease.
CHA2DS2-VASc is the curent risk factor tool for clinical practice;
Congestive heart failure (or Left ventricular systolic dysfunction) - 1
Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) - 1
A2 Age ≥75 years - 2
Diabetes Mellitus - 1
S2 Prior Stroke or TIA or thromboembolism - 2
Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque) - 1
Age 65–74 years - 1
Sex category (i.e. female sex) - 1
This patient therefore scores 4, equating to a 4% annual stroke risk. Any score of 2 or greater requires Warfarin (E) therapy, a score of 0 requires no treatment and a score of 1 would indicate consideration for warfarin or a newer anticoagulant.
A 55-year-old man has just arrived in accident and emergency complaining of 20
minutes of central crushing chest pain. Which feature is most indicative of
myocardial infarction at this moment in time?
A. Inverted T waves
B. ST depression
C. ST elevation
D. Q waves
E. Raised troponin
C. ST elevation
ACS is a spectrum of cardiac ischaemia-infarction determined by the prescence of two of three factors; ECG changes, cardiac chest pain and cardiac enzyme rise. Patients will be either NSTEMI, STEMI, or unstable angina.
Inverted T-waves (A) and ST depression (B) are both signs of ischaemia.
ST elevation (C), Q waves (D) and raised troponin (E) are indicitive of infarction.
The ST status of patients is used to stratify thier risk prior to the Troponin results. troponin levels should be taken immediately on presentation and after 3 hours, when most infarctions will be detectable. A normal troponin at 12 hours rules out an MI.
Those patients who present with ST elevation will need consideration for immediate PCI. This will usually be present before any detectable troponin raise, and certainly before the development of Q waves, which indicate a full-thickness MI.
A 66-year-old woman presents to accident and emergency with a 2-day history of
shortness of breath. The patient notes becoming progressively short of breath as
well as a sharp pain in the right side of the chest which is most painful when taking
a deep breath. The patient also complains of mild pain in the right leg, though there
is nothing significant on full cardiovascular and respiratory examination. Heart
rate is 96 and respiratory rate is 12. The patient denies any weight loss or long haul
flights but mentions undergoing a nasal polypectomy 3 weeks ago. The most likely
diagnosis is:
A. Muscular strain
B. Heart failure
C. Pneumothorax
D. Angina
E. Pulmonary embolism
E. Pulmonary embolism
The patient has had surgery prior to his symptoms, he has shortness of breath and sharp inspirational pain, and unilateral lower leg tenderness. Taking these factors into account a pulmonary embolus (E) seems the most likely diagnosis.
On examination you may find; a pleural rub, coarse crackles and atrial fibrilation. In the case of a massive PE there may be a raised JVP, hypotension, raised resp rate and heart rate. The likelhood of a PE can be assesed with a tool such as a Well’s score, there is another Well’s score for assesing DVT likelihood.
The other options here are unlikely; Muscular strain (A) will not produce shoness of breath or leg pain, and would be associated with movement. You would expect a suggestion of injury in the history.
Heart failure (B) is not an acute presentation and would likely be associated with right or left heart symptoms; ascites, hepatomegaly, oedema, / bibasal crepitations, raised JVP, orthopnea. There may also be murmurs on examination
A pneumothorax (C) can present similarly but the specific menion of leg pain tells you what the question wants you to think.
Angina (D) has a different character of pain, and again, the leg pain doesn’t fit.
A 59-year-old man presents for a well person check. A cardiovascular, respiratory,
gastrointestinal and neurological examination is performed. No significant findings
are found, except during auscultation a mid systolic click followed by a late systolic
murmur is heard at the apex. The patient denies any symptoms. The most likely
diagnosis is:
A. Barlow syndrome
B. Austin Flint murmur
C. Patent ductus arteriosus
D. Graham Steell murmur
E. Carey Coombs murmur
A. Barlow syndrome
In this scenario what we are hearing is the click as a thickened mitral valve leaflet is displaced into the left atrium, and then a murmur as there is regurgitation. This is termed Barlow syndrome (A).
An Austin Flint murmur (B) is a low pitched, mid-diastolic rumble at the apex. This can be seen in mitral valve displacement as well as aortic turbulance due to regurgitation.
a PDA (C) produces a constant, harsh, machine-like murmur.
A Graham Steell (D) is a high pitched murmur associated with pulmonary hypertension, heard over the pulmonary valve area during inspiration.
Carey Coombs murmur (E) is a short, mid-diastolic rumble heard best over the apex due to turbulant flow over a thickened mitral valve, often due to rheumatic fever.
A 60-year-old man presents to accident and emergency with a 3-day history of
increasingly severe chest pain. The patient describes the pain as a sharp, tearing
pain starting in the centre of his chest and radiating straight through to his back
between his shoulder blades. The patient looks in pain but there is no pallor, heart
rate is 95, respiratory rate is 20, temperature 37°C and blood pressure is
155/95 mmHg. The most likely diagnosis is:
A. Myocardial infarction
B. Myocardial ischaemia
C. Aortic dissection
D. Pulmonary embolism
E. Pneumonia
C. Aortic dissection
This is a classic description of aortic dissection (C), this needs emergency intervention.
The pain described in an Myocardial ischaemia/infarction (A)(B) would more classically be a central crushing chest pain. From an exam technique perspective there would be no way to distinguish ischaemia from infarction without an ECG so these could never be the answer.
There isn’t any convincing symptoms for pulmonary pathology in this history making (D) and (E) unlikely.
A 49-year-old man is rushed to accident and emergency complaining of a 20-minute
history of severe, crushing chest pain. After giving the patient glyceryl trinitrate
(GTN) spray, he is able to tell you he suffers from hypertension and type 2 diabetes
and is allergic to aspirin. The most appropriate management is:
A. Aspirin
B. Morphine
C. Heparin
D. Clopidogrel
E. Warfarin
D. Clopidogrel
In the case of acute coronary syndromes the reccomendation is to administer ‘MONA’, morphine, oxygen, nitrates, aspirin. In this case the GTN has been given, oxygen therapy isn’t an option, and he is allergic to aspirin (A), so that is not an appropriate choice. As there has been an appropriate response to GTN the morphine is a lower priority, the aspirin is the intervention with a beneficial effect on mortality/morbidity so there needs to be a thrombolytic agent given now. The Heparin (C) and Warfarin (E) would work but are both too slow. The guidance is that if a patient is allergic to aspirin then they should be given 300mg Clopidogrel.
While on call you are called by a nurse to a patient on the ward complaining of
light headedness and palpitations. When you arrive the patient is not conscious but
has a patent airway and is breathing with oxygen saturation at 97 per cent. You try
to palpate a pulse but are unable to find the radial or carotid. The registrar arrives
and after hearing your report of the patient decides to shock the patient who
recovers. What is the patient most likely to have been suffering?
A. Torsades de Pointes
B. Ventricular fibrillation
C. Sustained ventricular tachycardia
D. Non-sustained ventricular tachycardia
E. Normal heart ventricular tachycardia
B. Ventricular fibrillation
The fact that the registar has shocked the patient tells you that this must have been VF (B) or pulseless VT (C), of these options (C) doesn’t specifically say pulseless VT, as a normal sustained VT can be cardioverted medically with amiodorone if stable.THis makes this more likely to be VF in the context of this SBA question.
Of the non-shockable rhythms here; Torsades de pointes (A) is the presentation of irregular QRS complexes and prolonged QT interval.
A non-sustained VT (D) is a run of more than 5 consecutive beats in 30 seconds.
Finally (E) is a benign tachyarrhythmia.
A 67-year-old man presents to accident and emergency with a 3-day history of
shortness of breath. On examination you palpate the radial pulse and notice that
the patient has an irregular heart beat with an overall rate of 140 bpm. You request
an electrocardiogram (ECG) which reveals that the patient is in atrial fibrillation.
Which of the following would you expect to see when assessing the JVP?
A. Raised JVP with normal waveform
B. Large ‘v waves’
C. Cannon ‘a waves’
D. Absent ‘a waves’
E. Large ‘a waves’
D. Absent ‘a waves’
JVP waves are an idication of right atrial filling and pressures, there are 5 wave forms;
a wave – representing atrial systole;
c wave – representing closure of the tricuspid valve (this wave is not usually visible);
x descent – representing a fall in atrial pressure during ventricular systole;
v wave – representing atrial filling against a closed tricuspid valve;
y descent – representing the opening of the tricuspid valve.
of the options here; a normal wave form in a raised JVP (A) is seen in fluid overload and ight heart failure.
Large v waves (B) are seen in tricuspid regurgitation.
Cannon a waves (C) are seen in complete heart block as as a right atrium contracts agains a closed mitral valve. Also seen in ventricular arrythmias/ectopics, and sigle ventricular pacing, in essence anything that causes an uncoupling of atrial and ventricular contrction to the point where they occur simultaneously.
In AF the dysfuntion of the atrium leads to absent a waves (D)
Large a waves (E) can be seen in pulmonary hypertension and pulmonary stenosis.
A 78-year-old woman is admitted to your ward following a 3-day history of
shortness of breath and a productive cough of white frothy sputum. On auscultation
of the lungs, you hear bilateral basal coarse inspiratory crackles. You suspect that
the patient is in congestive cardiac failure. You request a chest x-ray. Which of the
following signs is not typically seen on chest x-ray in patients with congestive
cardiac failure?
A. Lower lobe diversion
B. Cardiomegaly
C. Pleural effusions
D. Alveolar oedema
E. Kerley B lines
A. Lower lobe diversion
Cardiomegaly (B), bilateral pleural effusions (C), alveolar oedema (D) and
Kerley B lines (E) (representing interstitial oedema) are all features that can be
seen in a chest x-ray in patients with congestive cardiac failure. Upper lobe
diversion is usually seen on chest x-ray and not lower lobe diversion (A).
A 56-year-old man presents to your clinic with symptoms of exertional chest
tightness which is relieved by rest. You request an ECG which reveals that the
patient has first degree heart block. Which of the following ECG abnormalities is
typically seen in first degree heart block?
A. PR interval >120 ms
B. PR interval >300 ms
C. PR interval <200 ms
D. PR interval >200 ms
E. PR interval <120 ms
D. PR interval >200 ms
The PR interval is usually measured from the start of the P-wave to the start
of the QRS and the normal range lies within 0.12–0.2s (i.e. 120–200 ms). In first degree heart block, the PR interval is prolonged, greater than 0.2 s
(200 ms) (D).
Shortened PR interval (i.e <120 s or <0.12 s) (E) results from
fast AV conduction, usually down an accessory pathway seen in Wolff–
Parkinson–White syndrome.
You see a 57-year-old woman who presents with worsening shortness of breath
coupled with decreased exercise tolerance. She had rheumatic fever in her
adolescence and suffers from essential hypertension. On examination she has signs
which point to a diagnosis of mitral stenosis. Which of the following is not a
clinical sign associated with mitral stenosis?
A. Malar flush
B. Atrial fibrillation
C. Pan-systolic murmur which radiates to axilla
D. Tapping, undisplaced apex beat
E. Right ventricular heave
C. Pan-systolic murmur which radiates to axilla
A pan-systolic murmur, radiating to the axilla (C) most likely indicates a mitral regurgitation and so is incorrect here. It may also be found in tricuspid regurgitation and VSD.
The other signs here are all seen in mitral stenosis. the murmur clasic of mitral stenosis would be a mid-diastolic, potentially with an opening snap.
A 48-year-old woman has been diagnosed with essential hypertension and was
commenced on treatment three months ago. She presents to you with a dry cough
which has not been getting better despite taking cough linctus and antibiotics. You
assess the patient’s medication history. Which of the following antihypertensive
medications is responsible for the patient’s symptoms?
A. Amlodipine
B. Lisinopril
C. Bendroflumethiazide
D. Frusemide
E. Atenolol
B. Lisinopril
ACE inhibitors classiclly cause a dry cough, Lisinopril (B) is the ACEi in this scenario and is likely responsible for the patient’s symptoms. The patient should be switched to either an angiotensin receptor blocker (E.G. irbesartan, losartan, telmisartan) or a different class of anti-hypertensive.
None of the other drugs in this scenario commonly cause a dry cough.
A 62-year-old male presents with palpitations, which are shown on ECG to be atrial
fibrillation with a ventricular rate of approximately 130/minute. He has mild
central chest discomfort but is not acutely distressed. He first noticed these about 3
hours before coming to hospital. As far as is known this is his first episode of this
kind. Which of the following would you prefer as first-line therapy?
A. Anticoagulate with heparin and start digoxin at standard daily dose
B. Attempt DC cardioversion
C. Administer bisoprolol and verapamil, and give warfarin
D. Attempt cardioversion with IV flecainide
E. Wait to see if there is spontaneous reversion to sinus rhythm
B. Attempt DC cardioversion
There is a recent onset of arrhythmia so there is a good chance of succesful cardioversion and there is no need for anticoagulation (A)(C).
DC cardioversion (B) has the best chance of success, although chemical cardioversion (D) may be preffered by the patient.
Digoxin may eventually control resting heart rate, but would take days to have an effect.
Option (C) could actually be a good option where there is persistant atrial fibrilation and it has been decided to opt out of rate control.
