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Question 1
Correct
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A 28-year-old male was admitted with palpitations and chest discomfort for the past 1 hour. On examination his pulse rate was 200 bpm and blood pressure was 80/50 mmHg. His ECG revealed narrow complex tachycardia with a heart rate of 200 bpm. Which of the following is the most appropriate management of this patient?
Your Answer: Synchronised DC synchronised cardioversion
Explanation:Narrow complex tachycardia with hypotension is a medical emergency. Immediate synchronized cardioversion is the ideal management.
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This question is part of the following fields:
- Cardiovascular System
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Question 2
Correct
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A 50-year-old smoker with a history of hypertension presented with acute severe chest pain and acute myocardial infarction was diagnosed. Which of the following is a contraindication for thrombolysis?
Your Answer: History of likely ischaemic stroke within the past month
Explanation:Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial haemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months -
This question is part of the following fields:
- Cardiovascular System
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Question 3
Incorrect
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Patients on digoxin therapy are required to receive an initially higher dose of the drug, in order to amplify the effect of the treatment. Which of the following makes this requirement necessary?
Your Answer:
Correct Answer: Half-life
Explanation:A loading dose is required for drugs that are eliminated from the body in a slow, progressive manner. Half-life is the indicator showing if a drug has a fast, intermediate or slow elimination rate.
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This question is part of the following fields:
- Cardiovascular System
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Question 4
Incorrect
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Which type of myocardial infarction has the worst prognosis?
Your Answer:
Correct Answer: Anterior wall MI complicated with continuing left ventricular failure and an exercise tolerance of 3 METS on a predischarge exercise test
Explanation:Exercise tolerance of 3 METS on a predischarge exercise test is the most important indicator of a poor post-MI prognosis. Other similar features that predispose the individual to a poor prognosis are resuscitation from a secondary ventricular tachyarrhythmia after the fist 24h and poor left ventricular function on echo.
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This question is part of the following fields:
- Cardiovascular System
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Question 5
Incorrect
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A 2-day-old girl is admitted by her mother because she gets cyanotic upon feeding and she wouldn't stop crying. The doctors suspect a congenital heart disease. What is the most probable aetiology?
Your Answer:
Correct Answer: Transposition of the great arteries
Explanation:Transposition of the great arteries results in a significant hypoxemic status that is observed clinically by central cyanosis. The bluish discoloration of the skin and mucous membranes is therefore the basic pattern of clinical presentation in transposition. Its onset and severity depend on anatomical and functional variants that influence the degree of mixing between the two circulations. Limited intercirculatory mixing, usually present if the ventricular septum is intact or the atrial septal defect is restrictive, is related to progressive and profound central cyanosis evident within the first hours of life. Tachypnoea, tachycardia, diaphoresis, poor weight gain, a gallop rhythm, and eventually hepatomegaly can be then detected later on during infancy. Heart murmurs associated with left outflow tract obstruction, due to a persistent arterial duct or a septal defect may be heard, but they are not a constant finding.
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This question is part of the following fields:
- Cardiovascular System
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Question 6
Incorrect
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A 44-year-old man complains of unceasing chest pain which is aggravated by inspiration four weeks after his MI. His temperature is 37.5C and ESR is 45mm/h. What is the single most likely explanation for the abnormal investigations
Your Answer:
Correct Answer: Dressler syndrome
Explanation:Dressler syndrome signs and symptoms include pericarditis, low-grade fever, and pleuritic chest pain. It commonly occurs two to five weeks following the initial event or for as long as three months.
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This question is part of the following fields:
- Cardiovascular System
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Question 7
Incorrect
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A 65-year-old male presented with acute ST elevation myocardial infarction and thrombolysis was planned. Which of the following is an absolute contraindication for thrombolysis?
Your Answer:
Correct Answer: Intracerebral Haemorrhage
Explanation:Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial haemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months -
This question is part of the following fields:
- Cardiovascular System
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Question 8
Incorrect
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A 59-year-old man complains of weakness in his right lower and upper limb since 3 for a few hours. He is has been taking Digoxin for 2 years. What is the most definitive investigation for this condition?
Your Answer:
Correct Answer: Angiography
Explanation:Digoxin is a cardiac glycoside, having positive inotropic effects on the heart. It increases the strength of contractility of the heart, increasing the heart rate, but lowering blood pressure. This patient developed weakness in his limbs most likely caused by extremely low blood pressure that could be due to diseased blood vessels reacting to the side-effects of digoxin, therefore an angiography would be the best investigation.
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This question is part of the following fields:
- Cardiovascular System
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Question 9
Incorrect
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A 70-year-old man underwent temporary transvenous pacing. While in the coronary care unit he developed presyncope. His pulse rate was 30 bpm. His ECG showed pacing spikes which were not related to QRS complexes. What is the most appropriate action that can be taken?
Your Answer:
Correct Answer: Increase the pacing voltage to a maximum
Explanation:Pacemaker spikes on the ECG indicate that pacemaker is functioning. The most probable cause for this presentation is the change of the position of the tip of the pacing wire. Increasing the voltage will solve the problem. If it works, repositioning of the pacing wire should be done.
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This question is part of the following fields:
- Cardiovascular System
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Question 10
Incorrect
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Which of the following is not an indication for an implantable cardiac defibrillator?
Your Answer:
Correct Answer: Wolff-Parkinson White syndrome
Explanation:Class I indications (i.e., the benefit greatly outweighs the risk, and the treatment should be administered): -Structural heart disease, sustained VT
-Syncope of undetermined origin, inducible VT or VF at electrophysiologic study (EPS)
-Left ventricular ejection fraction (LVEF) ≤35% due to prior MI, at least 40 days post-MI, NYHA class II or III
-LVEF ≤35%, NYHA class II or III
-LVEF ≤30% due to prior MI, at least 40 days post-MI
-LVEF ≤40% due to prior MI, inducible VT or VF at EPSClass IIa indications (i.e., the benefit outweighs the risk and it is reasonable to administer the treatment):
-Unexplained syncope, significant LV dysfunction, nonischaemic cardiomyopathy
-Sustained VT, normal or near-normal ventricular function
-Hypertrophic cardiomyopathy with 1 or more major risk factors
-Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) with 1 or more risk factors for sudden cardiac death (SCD)
-Long QT syndrome, syncope or VT while receiving beta-blockers
-Nonhospitalized patients awaiting heart transplant
-Brugada syndrome, syncope or VT
-Catecholaminergic polymorphic VT, syncope or VT while receiving beta-blockers
-Cardiac sarcoidosis, giant cell myocarditis, or Chagas disease -
This question is part of the following fields:
- Cardiovascular System
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Question 11
Incorrect
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The ECG of a 48-year-old man shows broad complex tachycardia with a HR of 154 bpm 2 days after an MI. His BP is 90/60 mmHg and he is complaining of palpitations and dyspnoea. What is the most appropriate management?
Your Answer:
Correct Answer: DC Shock
Explanation:Dysrhythmias are the most frequent MI complication. The patient seems to have a post MI atrial fibrillation which is treated, in an emergency context, with DC shock.
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This question is part of the following fields:
- Cardiovascular System
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Question 12
Incorrect
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A 60-year-old female presented with difficulty in breathing. What is the clinical sign that will indicate the presence of established pulmonary hypertension?
Your Answer:
Correct Answer: Raised jugular venous pressure
Explanation:A prominent A wave is observed in the jugular venous pulse and this indicates the presence of established pulmonary hypertension. In addition the pulmonic component of the second heart sound (P2) may be increased and the P2 may demonstrate fixed or paradoxical splitting. The signs of right ventricular failure include a high-pitched systolic murmur of tricuspid regurgitation, hepatomegaly, a pulsatile liver, ascites, and peripheral oedema.
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This question is part of the following fields:
- Cardiovascular System
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Question 13
Incorrect
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A 65-year-old heavy smoker presented with acute central chest pain for 2 hours. Which of the following ECG findings is an indication for thrombolysis in this patient?
Your Answer:
Correct Answer: 1 mm ST elevation in 2 limb leads
Explanation:Thrombolytic therapy is indicated in patients with evidence of ST-segment elevation MI (STEMI) or presumably new left bundle-branch block (LBBB) presenting within 12 hours of the onset of symptoms if there are no contraindications to fibrinolysis. STEMI is defined as new ST elevation at the J point in at least two contiguous leads of 2 mm (0.2 mV) or more in men or 1.5 mm (0.15 mV) in women in leads V2-V3 and/or 1 mm (0.1 mV) or more in other contiguous limb leads.
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This question is part of the following fields:
- Cardiovascular System
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Question 14
Incorrect
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A 60-year-old male patient with a history of heavy smoking was admitted complaining of acute severe central chest pain for the past one hour. His blood pressure was 150/90 mmHg and pulse rate was 88 bpm. His peripheral oxygen saturation was 93%. ECG showed ST elevation > 2 mm in lead II, III and aVF. He was given loading doses of aspirin, clopidogrel and atorvastatin and face mask oxygen was given. Which one of the following investigations should be done and then depending on result, definitive treatment can be initiated?
Your Answer:
Correct Answer: None
Explanation:The history and ECG findings are adequate to begin cardiac revascularization of this patient. There is no need for cardiac markers to confirm the diagnosis. Further delay in starting definite treatment is not recommended.
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This question is part of the following fields:
- Cardiovascular System
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Question 15
Incorrect
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A 72-year-old male with a history of type II diabetes mellitus and hypertension for 15 years, presented with gradual onset difficulty in breathing on exertion and bilateral ankle swelling for the past 3 months. On examination he had mild ankle oedema. His JVP was not elevated. His heart sounds were normal but he had bibasal crepitations on auscultation. Which of the following clinical signs has the greatest sensitivity in detecting heart failure in this patient?
Your Answer:
Correct Answer: Third heart sound
Explanation:The presence of a third heart sound is the most sensitive indicator of heart failure. All of the other signs can be found in heart failure with varying degrees.
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This question is part of the following fields:
- Cardiovascular System
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Question 16
Incorrect
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A 8-year-old girl with suspected patent foramen ovale, presented with her parents for the confirmation of the diagnosis. Which of the following is the best investigation to confirm the diagnosis?
Your Answer:
Correct Answer: Transoesophageal Echocardiography
Explanation:A 3-dimensional transoesophageal echocardiography (3D TEE) provides direct visualization of the entire PFO anatomy and surrounding structures. It allows more accurate diagnosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 17
Incorrect
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A 28-year-old male was screened for hypertrophic cardiomyopathy (HOCM). His father has passed away recently at the age of 48 and found to have HOCM during post mortem examination. On examination of this patient his BP was 142/84 mmHg and pulse rate was 68 bpm which was regular. There was a mid systolic murmur and a double apex beat. Echocardiography showed a septal wall thickness of 3.3 cm. What is the factor most closely linked to his 20 year risk of sudden cardiac death?
Your Answer:
Correct Answer: Septal wall thickness of 3.3 cm
Explanation:There are five prognostic factors which indicate poor prognosis in HOCM:
-family history of HOCM-related sudden cardiac death
-unexplained recent syncope
-large left ventricular wall thickness (MLVWT > 30 mm)
-multiple bursts of nsVT on ambulatory electrocardiography
-hypotensive or attenuated blood pressure response to exercise -
This question is part of the following fields:
- Cardiovascular System
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Question 18
Incorrect
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A 32-year-old male who was on methadone has suddenly collapsed while running and was found dead. What is the most likely cause for his death?
Your Answer:
Correct Answer: Prolonged QT
Explanation:Methadone and cocaine can cause QT prolongation through the direct effects on the resting membrane potential. Methadone can increase QT dispersion in addition to QT interval. Methadone inhibits the Human Ether-a-go-go Related Gene (hERG) and causes QTc prolongation and development of Torsades de point. Brugada-like syndrome is another condition found in methadone users which predisposes the users to life-threatening ventricular tachycardia and sudden cardiac death.
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This question is part of the following fields:
- Cardiovascular System
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Question 19
Incorrect
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In which condition are β-blockers not recommended as the first line of therapy?
Your Answer:
Correct Answer: Hypertension
Explanation:For patients with hypertension, ACE inhibitors, diuretics, or calcium-channel blockers are given as first-line pharmacological agents. Patients with angina, chronic heart failure, myocardial infarction, and permanent atrial fibrillation with rapid ventricular rate, are given β-blockers as first-line therapy. In these cases, increased cardiac activity can not be met by the amount of blood being supplied to the heart. Giving β-blockers will reduce the workload of the heart and slow down the cardiac activity.
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This question is part of the following fields:
- Cardiovascular System
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Question 20
Incorrect
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A 71-year-old female presents with a pansystolic murmur. History reveals a myocardial infarction which manifested three days ago. What is the most likely cause of the murmur?
Your Answer:
Correct Answer: Rupture of papillary muscle
Explanation:A pan-systolic murmur is the result of mitral regurgitation. Mitral regurgitation in this case is most probably due to post-MI rupture of the papillary muscle of the mitral valve.
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This question is part of the following fields:
- Cardiovascular System
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Question 21
Incorrect
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A 54-year-old patient presented with a dry cough after starting treatment for hypertension. He was prescribed ramipril 2.5mg and the dry cough started after that, which disturbed his sleep. His blood pressure was normal. Which of the following is the most appropriate management?
Your Answer:
Correct Answer: Stop the ramipril and prescribe candesartan
Explanation:ACE inhibitors are known to cause a dry cough and they should be stopped, to settle the cough. The next drug of choice is an angiotensin receptor blocker such as candesartan.
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This question is part of the following fields:
- Cardiovascular System
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Question 22
Incorrect
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A 60-year-old man presented with severe central chest pain for the last 2 hours. He was on insulin for diabetes mellitus and he was dependent on haemodialysis because of end stage renal failure. He had undergone haemodialysis 48 hours prior to this presentation. His ECG showed an acute inferior myocardial infarction. Despite thrombolysis and other appropriate treatment, he continued to have chest pain after 6 hours from the initial presentation. His blood pressure was 88/54 mmHg and he had bibasal crepitations. His investigation results are given below.
Serum sodium 140 mmol/l (137-144)
Serum potassium 6.6 mmol/l (3.5-4.9)
Serum urea 50 mmol/l (2.5-7.5)
Serum creatinine 940 μmol/l (60-110)
Haemoglobin 10.2g/dl (13.0-18.0)
Troponin T >24 g/l (<0.04)
Left ventricular ejection fraction was 20%
What is the most appropriate management for this patient?Your Answer:
Correct Answer: Coronary angiography and rescue PCI
Explanation:According to the history the patient has cardiogenic shock and pulmonary oedema. On-going ischaemia is indicated by persisting symptoms. So the most appropriate management is coronary angiography and rescue PCI. There are no indications for blood transfusion at this moment and it will aggravate the pulmonary oedema. Haemodialysis, beta blockers and furosemide cannot be given due to low blood pressure.
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This question is part of the following fields:
- Cardiovascular System
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Question 23
Incorrect
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In a patient with cardiomyopathy, which one of the following statements would be aetiologically significant?
Your Answer:
Correct Answer: The presence of diabetes mellitus in a tanned patient
Explanation:Hemochromatosis is a condition that leads to abnormal iron deposition in specific organs. There are two main types: primary (hereditary) and secondary (e.g., transfusion-related). The most common form is hereditary autosomal recessive hemochromatosis type 1, which is caused by an underlying genetic defect that results in partially uninhibited absorption of iron in the small intestine.
Hemochromatosis is mostly asymptomatic but can become symptomatic, usually between the third and fifth decade of life, when poisonous levels of iron have had time to accumulate in the body. Symptoms include fatigue, hyperpigmentation, diabetes mellitus (bronze diabetes), and arthralgia. The deposits may lead to various organ diseases, the most typical being the development of liver cirrhosis, which is accompanied by an increased risk of hepatocellular carcinoma (HCC). Serum ferritin and transferrin saturation levels are typically elevated. Molecular genetic testing or a liver biopsy may be used to confirm the diagnosis. Treatment primarily consists of repeated phlebotomy to reduce iron levels. In addition, dietary changes and drug therapy (chelating agents such as deferoxamine) may be used to influence the amount of iron in the body. -
This question is part of the following fields:
- Cardiovascular System
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Question 24
Incorrect
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A 65-year-male patient was started on warfarin for chronic atrial fibrillation (AF). Which of the following clotting factors is not affected by warfarin?
Your Answer:
Correct Answer: Factor XII
Explanation:Carboxylation of factor II, VII, IX, X and protein C is affected by warfarin. Factor XII is not affected.
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This question is part of the following fields:
- Cardiovascular System
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Question 25
Incorrect
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A 13-year-old boy presented with difficulty in breathing on exertion. According to his mother who was also present, his exercise tolerance has been gradually worsening for the past weeks. It has reached the point where he is unable to participate in his weekly soccer match. Cardiac catheterization was performed and the results are given below.
Anatomical site
Oxygen saturation (%)
Pressure (mmHg)
Superior vena cava
73
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Right atrium
71
6
Right ventricle
72
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Pulmonary artery
86
53/13
PCWP
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15
Left ventricle
97
111/10
Aorta
96
128/61
Which of the following is the diagnosis?Your Answer:
Correct Answer: Patent ductus arteriosus
Explanation:The oxygen saturation in the pulmonary artery is higher than that of the right ventricle. The pressure of the pulmonary artery and of the PCWP are also high. So patent ductus arteriosus is highly suggestive.
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This question is part of the following fields:
- Cardiovascular System
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Question 26
Incorrect
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A 55-year-old female with a history of hypertension presented with severe central chest pain for the past one hour, associated with sweating and vomiting. Her ECG showed ST elevation myocardial infarction, evident in leads V2-V4. Which of the following is an absolute contraindication for thrombolysis?
Your Answer:
Correct Answer: Intracranial neoplasm
Explanation:Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial haemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months -
This question is part of the following fields:
- Cardiovascular System
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Question 27
Incorrect
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A 45-year-old male complains of angina pain. Which of the following features on exercise testing would have the strongest predictive value for ischaemic heart disease?
Your Answer:
Correct Answer: Decline in systolic BP by 20 mmHg in stage 1 of the Bruce protocol
Explanation:The classic criteria for visual interpretation of positive stress test findings include the following:J point (the junction of the point of onset of the ST-T wave; it is normally at or near the isoelectric baseline of the ECG), ST80 (the point that is 80 msec from the J point), depression of 0.1 mV (1 mm) or more and ST-segment slope within the range of ± 1 mV/sec in 3 consecutive beats
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This question is part of the following fields:
- Cardiovascular System
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Question 28
Incorrect
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A 40 years old man collapsed at home and died. The GP's report says he suffered from type 2 Diabetes Mellitus and his BMI was 35. What is the most likely cause of death?
Your Answer:
Correct Answer: Myocardial infarction
Explanation:Diabetic patients usually have a higher risk of developing cardiovascular events by 2-4x that of the general population. In addition, diabetic patients are often obese and possibly have hyperlipidaemia, which are great risk factors of cardiovascular incidents.
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This question is part of the following fields:
- Cardiovascular System
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Question 29
Incorrect
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A 26-year-old male was being investigated further following several hypertensive episodes. There was a marked difference in his systolic blood pressures between the right brachial and the right femoral arteries. Which of the following is most probable diagnosis?
Your Answer:
Correct Answer: Coarctation of the aorta
Explanation:From the given physical findings (the difference in BP between the radial and femoral arteries), the most probable diagnosis is coarctation of the aorta.
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This question is part of the following fields:
- Cardiovascular System
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Question 30
Incorrect
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A 59-year-old man experienced an acute chest pain, which lasted for 45 mins whilst he was driving. The pain was located centrally and was accompanied by cold sweats and difficulty in speaking. History reveals he is a T1DM patient who's been on antihypertensive medication for 13 years. What is the most likely diagnosis?
Your Answer:
Correct Answer: Myocardial infarction
Explanation:The patient is diabetic and at major risk for an MI. The duration and location of the pain, the cold sweats and the difficulty in speaking suggest an MI. Pericarditis pain worsens upon inspiration or in a supine position. Patients usually lean forward to relieve the pain. (antalgic position). Pneumothorax pain is pleuritic in regards to location. Pulmonary embolism is accompanied by dyspnoea and pleuritic pain. Costochondritis pain is localized at the costochondral junction and it worsens with movements of the chest such as coughing or sneezing.
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This question is part of the following fields:
- Cardiovascular System
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SESSION STATS - PERFORMANCE PER SPECIALTY
