MCQ Flashcards
A 45 year old man undergoes a metallic aortic valve replacement for aortic stenosis due to a congenital bicuspid valve. He has a past medical history of hypertension. He is a smoker and drinks 25 units of alcohol per week. Surgery is uncomplicated. Which of the following is the most appropriate choice of anticoagulant for his long-term management?
Dabigatran
Aspirin
Warfarin
Enoxaparin
Rivaroxaban
Answer: C - Warfarin
Rationale:
Warfarin is the only anticoagulant licensed for long term anticoagulation for mechanical valve replacement.
Aspirin is not an anticoagulant DOACs (Dabigatran/rivaroxaban) are not licenced for this indication due to safety concerns (bleeding/thrombus).
Enoxaparin can be used, but is not typically first choice for long term anticoagulation
Source:
Handbook of Clinical Medicine 4th edition, Cardiology, Valvular Heart Disease
A 52-year-old man presents to the emergency department. He has a one hour history of dull central chest pain extending down the ulnar aspect of his left arm. His blood pressure is 100/65 mmHg, heart rate 65 beats per minute, oxygen saturation 99% on room air. He appears pale and clammy. There is no elevated jugular venous pressure. His ECG is shown below. What is the diagnosis?
Lateral STEMI
Anterolateral STEMI
Posterior STEMI
Anterior STEMI
Inferior STEMI
Answer: E – Inferior STEMI
Rationale:
ST elevation in leads II, III, aVF
(i.e. inferior leads)
A 56-year-old male presents to the emergency department. He reports a two week history of recurrent drenching night sweats, malaise and severe fatigue. He has a background history of bio-prosthetic aortic valve replacement, hypertension and type 2 diabetes mellitus, and benign prostatic hypertrophy diagnosed 5 weeks ago after a cystoscopy and biopsy. Examination reveals a diastolic murmur at the left sternal edge. What is the next most appropriate diagnostic investigation?
C-reactive protein
Chest X-ray
Blood cultures
Electrocardiogram
Cardiac CT
Answer: C – Blood cultures
Rationale:
This patient’s history is suspicious for infective endocarditis. While all other tests will most likely be performed, CRP, CXR and ECG are unlikely to be diagnostic. Cardiac CT can confirm a diagnosis of IE however it would not be the next most appropriate test.
A 76-year-old male is admitted following treatment for a NSTEMI. Later that night, the patient complains of light-headedness and shortness of breath. He denies chest pain. GCS is 14/15 and he appears pale. His heart rate is 170 beats per minute and his blood pressure is 76/30 mmHg. Rhythm strip from his telemetry is shown below. What is the most appropriate immediate management for this patient?
Transcutaneous pacing
Defibrillation
Amiodarone infusion
Percutaneous coronary intervention (PCI)
Synchronised cardioversion
Answer: E – synchronised cardioversion
Rationale:
This is a broad complex tachycardia – VT
The patient is unstable (reduced GCS, hypotension)
Immediate synchronised cardioversion is indicated
Pacing is not indicated (would be for unstable brady), defibrillation (unsynchronised shock) is not appropriate as there is a risk of triggering VF. Amiodarone infusion may be considered later after DCCV. Repeat PCI may be indicated but later.
Source:
RCSI Handbook of Clinical Medicine 4th edition, Cardiology, Ventricular arrhythmias chapter
A 77-year-old woman presents to the emergency department. She reports a one day history of increasing breathlessness. She has been unable to lie flat at night for the last 3 months and reports her shoes have been tighter. She denies chest pain, palpitations or dizziness. She has a history of a NSTEMI 5 years ago. Examination reveals an S3 and crepitations to the midzones bilaterally. Heart rate is 102/min, blood pressure 155/95 mmHg, oxygen saturation 95% on room air. What medication should be commenced?
Ramipril
Digoxin
Furosemide
Bisoprolol
Spironolactone
Answer: C - furosemide
Rationale:
This is most likely an acute exacerbation of chronic heart failure, based on the symptoms and signs.
For acute heart failure, in particular with pulmonary oedema, loop diuretics are usually the drug of choice to provide symptomatic relief. The other medications may be prescribed as part of her overall management but not acutely in this setting
