Revision questions Flashcards
A 23 year old female who has history of a cardiac condition wants to start a family with her husband and has been referred to the cardiology clinic for advice. What condition is an absolute contra indication to pregnancy?
a) Bicuspid aortic valve
b) ASD
c) PFO
d) Mitral valve prolapse
e) Primary pulmonary hypertension
e) Primary pulmonary hypertension
- Pulmonary hypertension is the only absolute contraindication as it can rapidly deteriorate during pregnancy.
- MVP and bicuspid aortic valve should be monitored. PFO and ASD are not contraindications.
A 68 year old asthmatic presents with shortness of breath. She also has a PMH of hypertension for which she is prescribed ramipril. On examination she is found to have a BP of 130/80mmHg, pulse of 90 irregularly, irregular and bilateral wheeze and normal heart sounds. A CXR reveals cardiomegaly.
What is the most appropriate treatment of her AF?
a) Verapamil
b) Flecainide
c) Atenolol
d) Amiodarone
e) Digoxin
e) Digoxin
- Rate control is the most appropriate in this case. Digoxin should be utilised due to the cardiomegaly and history of asthma which means verapamil and atenolol should be avoided due to potential of precipitating heart failure and worsening asthma respectively.
A 60 year old male presents with general malaise, pyrexia and night sweats. They have a past history of rheumatic heart disease. On examination there is evidence of a pansystolic murmur. Which is a new clinical finding. What organism is the most likely to have caused these symptoms?
a) Strep. Viridans
b) HACEK group
c) Staph. Aureus
d) Staph Epidermidis
e) MRSA
a) Strep. Viridans
- The most common organism to lead to infective endocarditis on a native valve is Strep Viridans. Staph Aureus and staph epidermidis are most likely to be the causative agents in prosthetic valve endocarditis. HACEK ad MRSA are both more rare causes.
A 75 year old presents with shortness of breath on exertion. On further questioning she is unable to lie flat due to breathlessness and has woken up during the night gasping for air. She has a history of hypertension. On examination there is bibasal crackles. The CXR reveals small bilateral pleural effusions, upper lobe diversion and bat wing oedema. What is the most likely diagnosis?
a) Cryptogenic fibrosing alveolitis
b) Pulmonary oedema
c) Interstitial lung disease
d) COPD
e) Pneumonia
b) Pulmonary oedema
- The patient describes orthopnoea and paroxysmal nocturnal dyspnoea which are characteristic of pulmonary oedema. The CXR is also indicative as pulmonary oedema shows bilateral pleural effusion, perihilar shadowing (bat wing oedema), upper lobe diversion and Kerley B lines. The background of hypertension suggests an underlying cause for her cardiac failure.
Which of the following suggests the presence of mitral regurgitation as well as mitral stenosis?
a) Displaced apex beat b) Raised JVP
c) Atrial fibrillation
d) Loud P2
e) Localised tapping apex beat
a) Displaced apex beat
- Mitral stenosis on its own does not lead to left ventricular dilatation and does not cause a displaced apex beat. If there is a displaced apex beat this is suggestive of mixed mitral disease. The other options occur in mitral stenosis.
A 81 year old male with a history of hypertension and inferior MI is seen in the cardiology clinic due to worsening angina and heart failure and 2 syncopal episodes. He is found to have an ejection systolic murmur loudest at the apex. Which investigation will confirm the most likely diagnosis?
a) Blood cultures
b) Coronary angiography
c) Exercise tolerance test
d) ECG
e) Echocardiography
e) Echocardiography
- Aortic Stenosis explains all of the symptoms of worsening angina and heart failure and the 2 episodes of syncope. Although the murmur is loudest at the apex mitral regurgitation is less likely to explain the syncopal episodes.An Echocardiograph will confirm the diagnosis. Coronary angiography should be performed but is not used for the diagnosis.
A 72 year old gentleman has recently had a mitral valve replacement. He is now complaining of fatigue and shortness of breath. On examination he is pale and his sclera appear yellow. Bloods reveal a low haemoglobin, increased bilirubin, increased reticulocyte count and fragmented red cells on blood film. What is the most likely diagnosis?
a) B12 deficiency
b) Cholangitis
c) Iron deficiency anaemia
d) Infective endocarditis
e) Haemolytic anaemia
e) Haemolytic anaemia
- The most likely diagnosis is Haemolytic anaemia due to cardiac haemolysis. The mechanical valve can cause direct trauma to the red cells and thus lead to lysis. Haemolytic anaemia is evidenced by the reduced haemoglobin, increased reticulocyte count, increased LDH, increased unconjugated bilirubin and reduced haptoglobin. Spherocytes and fragmented red cells can appear on blood film.
Which of the following is not a feature of hypokalaemia on an ECG?
a) U wave
b) Prolonged QT
c) Flattened t wave
d) Delta wave
e) ST depression
d) Delta wave
A 62 year old has had two syncopal episodes. She complains of intermittent palpitations. There is nil of note on examination and her bloods are normal. What is a useful first investigation?
a) Echocardiogram
b) 24 hour ECG
c) EEG
d) Exercise tolerance test
e) Nil required
b) 24 hour ECG
- In a patient with syncopal episodes and a normal clinical examination who is complaining of intermittent palpitations, a 24 hour ECG is a reasonable first investigation. This will exclude any cardiac arrhythmias. In some patients reassurance is appropriate if the patient is young and it is clearly syncopal and no symptoms suggestive of cardiac disease. Aortic stenosis can lead to syncope however normally a murmur would be heard. If there was concern of this an echocardiogram should be organised.
A patient presents with chest pain and shortness of breath. She has rheumatoid arthritis. She is tachycardic and hypotensive. She has a raised JVP and an ECG shows low QRS voltages.
What is the most likely diagnosis?
a) Pericarditis
b) Cardiac tamponade
c) Constrictive pericarditis
d) Pulmonary fibrosis
e) Myocarditis
b) Cardiac tamponade
- Pericardial effusions can occur in rheumatoid arthritis and occur more commonly than constrictive pericarditis and acute pericarditis. In this case the effusion has led to tamponade as typified by the clinical findings. It leads to an increased JVP and classically although rarely seen Becks Triad of jugular venous distension, hypotension and diminished heart sounds. Pulsus paradoxus is also a feature. Pericarditis leads to saddled shaped ST elevation. Myocarditis shows variable ECG findings however does not explain all the clinical findings.
Which of the following suggests more severe mitral regurgitation?
a) Split S2
b) Loudness of murmur
c) Soft S1
d) Length of murmur
e) Displacement of apex beat and systolic thrill
e) Displacement of apex beat and systolic thrill
- As mitral regurgitation becomes more severe, the left ventricle enlarges and the apex beat displaces and a systolic thrill can develop.
A 65 year old gentleman with type 2 diabetes mellitus is found incidentally to have left bundle branch block on his ECG. It had not been present on previous ECGs. An ECHO reveals no structural abnormality. You want to exclude a myocardial infarct.
What investigation should be performed in the first instance?
a) Thalium perfusion scan
b) Exercise tolerance test
c) Coronary angiography
d) CT angiography
e) Repeat ECG
b) Exercise tolerance test
- An ETT should be performed in the first instance to investigate if there is any evidence of ischaemia. This should be performed before any more invasive tests such as angiography. A thallium perfusion scan can be utilised if the patient cannot manage an ETT.
An echocardiogram is performed on a patient prior to surgery and reveals a very small pericardial effusion but no other abnormalities. He is asymptomatic. What should be done regarding this prior to surgery?
a) NSAIDs
b) Proceed with surgery, nil required
c) Pericardial drain
d) Postpone surgery and perform further investigations
e) Troponin
d) Postpone surgery and perform further investigations
A 68 year old man visits his GP due to palpitations. He had had an MI in the past and LVF and is currently on losartan and furosemide. His pulse is irregularly irregular with a rate of 90, BP 102/70mmHg, normal heart sounds but bibasal crepitations. He is referred to cardiology and an ECHO reveals dilated LA and LV. Which drug should be utilised to control his AF?
a) Digoxin
b) Sotalol
c) Amiodarone
d) Flecainide
e) Diltiazem
a) Digoxin
- Digoxin is the most appropriate as it is useful in symptom control of cardiac failure. Chemical cardioversion is unlikely to be successful due to enlarged LA and LV. Flecainide again is for chemical cardioversion and should be avoided in structural heart disease and sotalol and diltiazem are negative intotropes and may worsen the cardiac failure.
A 35 year old gentleman has collapsed twice in the last month. He has a brother and uncle who died in their 20s of sudden cardiac death. An ECHO reveals features of HCOM and a 24 hour ECH shows several short runs of non sustained VT. How do you manage the non sustained VT?
a) Flecainide 100mg
b) Implantable cardiovertor defibrillator
c) Amiodarone 200mg
d) Atenolol 100mg
e) None required
b) Implantable cardiovertor
- Due to evidence of the non sustained VT he is at increased risk of sudden cardiac death and therefore an ICD is appropriate. Amiodarone was previously utilised for medical management but ICDs are now becoming management of choice.
A 23 year old present with palpitations intermittently. She is known to suffer from anxiety attacks. However on auscultation of the heart there is evidence of a late systolic murmur with a mid systolic click. It is worsened by the standing position.
What is the most likely diagnosis?
a) Aortic stenosis
b) Mitral stenosis
c) Mitral valve prolapse
d) Normal variant
e) Atrial Myxoma
c) Mitral valve prolapse
- The late systolic murmur with mid systolic click is indicative of mitral valve prolapse where the posterior leaflets bulge during systole. It has been associated with Ehlers Danlos syndrome and Marfans syndrome amongst others. It can very rarely lead to problems such as embolic events. Mitral stenosis causes a diastolic murmur and may be associated with other features such as haemoptysis. AS leads to an ejection systolic murmur. An atrial myxoma is a cardiac tumour and may lead to a mid diastolic murmur and tumour plop.
A 70 year old female has had several syncopal episodes. On auscultation there is an ejection systolic murmur radiating to the carotids.
What is the most likely diagnosis?
a) Simple vasovagal episodes
b) Arrthymia
c) Aortic stenosis
d) Mitral regurgitation
e) Hypertrophic cardiomyopathy
c) Aortic stenosis
- Aortic stenosis leads to an ejection systolic murmur radiating to the carotids. It can lead to anginal symptoms and syncopal episodes as in this case and heart failure. There has been some association with haemorrhagic telangiectasia and GI bleeding. MR leads to a pansystolic murmur radiating to the axillae. An arrhythmia may be occurring but given the presence of a murmur aortic stenosis is more likely.
A 45 year old male presents with palpitations. He had been drinking heavily the night before. His heart rate is about 140 bpm and is irregularly irregular. What is the most likely diagnosis?
a) Atrial flutter
b) Supraventricular tachycardia
c) Torsades de pointes
d) Paroxysmal atrial fibrillation
e) Ventricular tachycardia
d) Paroxysmal atrial fibrillation
- Given the history of alcohol excess and irregularly irregular pulse this is highly indicative of atrial fibrillation which commonly can occur after alcohol or caffeine excess.
In a patient with chest pain with some t wave flattening, which investigation will confirm an NSTEMI?
a) LDH
b) Troponin I
c) AST
d) CK-MB
e) Inflammatory markers
b) Troponin I
- Troponin I and troponin T are specific for myocardial infarction and are elevated within 6-12 hours. AST and LDH are elevated following an MI however these are not specific. CK-MB was previously utilised however troponin is more sensitive and specific.
A 65 year old gentleman attends the pre operative clinic. He is awaiting a knee replacement as he has severe osteoarthritis of his knee and hip. He has had a previous myocardial infarction and over the last few months has complained of what sounds like angina pain. Which of the following is useful initially in determining if there is evidence of myocardial ischaemia?
a) Echocardiogram
b) Exercise tolerance test
c) Myocardial perfusion scan
d) Coronary angiography
e) ECG
c) Myocardial perfusion scan
- An exercise tolerance test is normally utilised to assess if there is any evidence of myocardial ischaemia. However in those who are unable to exercise a myocardial perfusion scan can be utilised as an alternative as in this man’s case. This is is a non invasive test and if there is any evidence of ischaemia then obviously a coronary angiography would be required before surgery could proceed. An Echo is not useful in showing evidence of ischaemia.
A 50 year old female presents with shortness of breath, fatigue and peripheral oedema. On examination she has a raised JVP, pitting oedema, hepatomegaly and ascites. An echo is organised and reveals globally thickened walls oncluding the interatrial septa with atrial dilatation but the ventricles are not dilated. There is an increased scintillation pattern (granular speckling). There is a normal ejection fraction. An ECG shows low voltage complexes. Given the most likely diagnosis, how else might it present?
a) Embolic symptoms
b) Cardiac tamponade
c) Myocardial infarction
d) Liver failure
e) Renal failure
a) Embolic symptoms
- The most likely diagnosis is restrictive cardiomyopathy given the clinical features and echo findings. The clinical findings are similar to those of contrictive pericarditis however the echo in this condition would reveal thickened calcified pericardium and normal wall thickness. Due to the atrial dilatation thrombus formation can occur and patients may present with embolic symptoms.
A 65 year old woman during prep assessment is found to have a small pericardial effusion. She is asymptomatic. The rest of her examination, ECG and other investigations are normal.
How do you manage this patient?
a) Pericardiocentesis
b) NSAIDs
c) Coronary Angiography
d) Reassure
e) Furosemide
d) Reassure
- This patient can be reassured as there is no need for pericardiocentenis as the patient is asymptomatic and is haemodynamically stable.
A 52 year old gentleman is 5 days post STEMI when he starts to develop chest pain. It is pleurtic in nature and worse on lying down. He is pyrexial and generally unwell. On examination he is tachycardic and there is evidence of a pericardial friction rub. On ECG there is widespread ST elevation.
What is the most likely diagnosis?
a) Dresslers syndrome
b) Cardiac tamponade
c) STEMI
d) Pulmonary embolism
e) Pneumonia
a) Dresslers syndrome
- This patient presents with symptoms and signs of Dresslers syndrome. It is thought to be an immunological reaction which leads to pericarditis and presetns normally 2 to 5 days following MI but can present up to 3 months. As well as chest pain the patient is often suffering from malaise and pyrexia. There may a leucocytosis , eosinophilia and raised ESR. AS with any other causes of pericarditis pericardial; friction rub and widespread ST elevation may be evident.
A 50 year old female presents with shortness of breath, fatigue and peripheral oedema. On examination she has a raised JVP, pitting oedema, hepatomegaly and ascites. An echo is organised and reveals globally thickened walls including the interatrial septa with atrial dilatation but the ventricles were not dilated. There is an increased scintillation pattern (granular speckling). There is a normal ejection fraction. An ECG shows low voltage complexes. What is the most likely diagnosis?
a) Constrictive pericarditis
b) Restrictive cardiomyopathy
c) Arrhythmogenic right ventricular cardiomyopathy
d) Dilated cardiomyopathy
e) Hypertrophic cardiomyopathy
b) Restrictive cardiomyopathy
- The most likely diagnosis is restrictive cardiomyopathy given the clinical features and echo findings. The clinical findings are similar to those of constrictive pericarditis however the echo in this condition would reveal thickened calcified pericardium and normal wall thickness. Due to the atrial dilatation thrombus formation can occur and patients may present with embolic symptoms. The other options may be excluded from the echocardiogram findings. In HOCM patients tend no to present with features of right heart failure and on arrhythmogenic right ventricular cardiomyopathy would present with a ventricular arrhythmia. Amyloidosis is the most common cause of restrictive cardiomyopathy and the interatrial septal hypertrophy and granular speckling are suggestive of this as the underlying cause however are not specific and may be seen in other causes. Other causes include sacoidosis and Loefflers endocarditis.
A 50 year old female parents with shortness of breath, fatigue and peripheral oedema. On examination she has a raised JVP, pitting oedema, hepatomegaly and ascites. An echo is organised and reveals globally thickened walls oncluding the interatrial septa with atrial dilatation but the ventricles are not dilated. There is an increased scintillation pattern (granular speckling). There is a normal ejection fraction. An ECG shows low voltage complexes. Given the most likely diagnosis
Which drug should she be advised to avoid?
a) Ramipril
b) Digoxin
c) Forosemide
d) Bendroflumethiazide
e) Amiodarone
b) Digoxin
- The most likely diagnosis is restrictive cardiomyopathy given the clinical features and echo findings. The clinical findings are similar to those of constrictive pericarditis however the echo in this condition would reveal thickened calcified pericardium and normal wall thickness. Due to the atrial dilatation thrombus formation can occur and patients may present with embolic symptoms. Patients with restrictive cardiomyopathy most likely secondary to amyloidosis should avoid digoxin as it is thought that digoxin may bind to amyloid fibrils and lead to increased toxicity. There I some suggestion that calcium channel blockers and beta blockers should also be avoided.
A 52 year old gentleman is 5 days post STEMI when he starts to develop chest pain. It is pleuritic in nature and worse on lying down. He is pyrexial and generally unwell. On examination he is tachycardic and there is evidence of a pericardial friction rub. On ECG there is widespread ST elevation. Given the most likely diagnosis, what management should be initiated?
a) NSAIDs
b) Thrombolysis
c) IV heparin
d) PCI
e) IV antibiotics
a) NSAIDs
- This patient presents with symptoms and signs of Dresslers syndrome. It is thought to be an immunological reaction which leads to pericarditis and presents normally 2 to 5 days following MI but can present up to 3 months. As well as chest pain the patient is often suffering from malaise and pyrexia. There may a leucocytosis , eosinophilia and raised ESR. AS with any other causes of pericarditis pericardial; friction rub and widespread ST elevation may be evident. NSAIDs are useful in the management and corticosteroids have been used in patients with severe symptoms.
A 70 year old female has had several syncopal episodes. On auscultation there is an ejection systolic murmur radiating to the carotids. What is the most likely diagnosis?
a) Simple vasovagal episodes
b) Aortic stenosis
c) Mitral regurgitation
d) Arrhythmia
e) Hypertrophic cardiomyopathy
b) Aortic stenosis
- Aortic stenosis leads to an ejection systolic murmur radiating to the carotids. It can lead to anginal symptoms and syncopal episodes as in this case and heart failure. There has been some association with haemorrhagic telangiectasia and GI bleeding. MR leads to a pansystolic murmur radiating to the axillae. An arrhythmia may be occurring but given the presence of a murmur aortic stenosis is more likely.
A 66 year old male with a history of AF on aspirin and bisoprolol presents with symptoms of TIAs. An ECHO and a CT Head do not reveal any abnormalities. How would you manage this patient?
a) Warfarin
b) Carotid endarterectomy
c) Digoxin
d) Clopidogrel
e) Nil
a) Warfarin
- This patient is developing TIAs. On a background of AF this may be due to embolus and thus if there is no major contraindications then the patient should be fully anti-coagulated with warfarin. Previous recommendations say unless contraindicated patients with a history of previous stroke/TIA/thromboembolic event, those over 75 with hypertension, diabetes or vascular disease or those with evidence of valve disease or LVSD should be warfarinised although some suggest now it should be considered in all patients. Endarterectomy is utilised in those with significant carotid artery stenosis. Clopidogrel is not indicated in this case.
A patient has just suffered a STEMI and is now found to be in complete heart block. What vessel is likely to have been involved?
a) Right coronary artery
b) Left coronary
c) Left anterior descending artery
d) Left circumflex artery
e) Left marginal artery
a) Right coronary artery
- Conduction defects most commonly complicate inferior STEMIs. The inferior portion of the heart in the majority of people is supplied by the right coronary artery.
A 42 year old gentleman with Type 2 Diabetes Mellitus, hypertension and 20 a day smoker, attended A+E with severe crushing central chest pain, sweaty and nausea. His current medication is lisinopril, amlodipine and bendroflumethiazide. He looks diaphoretic, pale and anxious. There is nil else of note on examination. An ECG reveals ST Elevation in II, III and aVF. What is the next most appropriate step?
a) Aspirin, clopidogrel + LMWH
b) Await 12 hour troponin and ECG
c) Primary Percutaneous coronary intervention
d) Thrombolysis
e) Abcicimab
c) Primary percutaneous coronary intervention
- The evidence base shows that patients with acute STEMI should be referred for primary PCI as it is superior to thrombolysis. PCI should be considered first line management and if patients can reach a primary PCI centre within 90 minutes. Protocols vary in regions however often aspirin, clopidogrel and a bolus of heparin is given before PCI
A 35 year old female with rheumatoid arthritis presents with pain and tightness behind of the left leg. On examination there is evidence of a swelling in the popliteal fossa of the left knee. What investigation should be organised?
a) D dimers
b) MRI of knee
c) Ultrasound of popliteal fossa
d) Arthroscopy
e) Routine bloods
c) Ultrasound of popliteal fossa
- The most likely diagnosis is a Baker’s cyst and an ultrasound should be performed to confirm this. A d-dimer should only be measured if you suspect a DVT and according to the appropriate Well’s score.
Wells score is used to indicate DVT and pulmonary embolism.
