Cardiology

101. Which one of the following is characteristic of atrial myxoma? Usually originates in the right atrium Fragments of tumour easily break off and grow in its peripheral sites Echocardiogram is diagnostic in most cases The clinical signs can mimic severe mitral regurgitation Recurrence is frequent even after successful surgical removal of the tumour

Your answer

Atrial myxoma is a benign tumour of the heart. Approximately 75% originate in the left atrium. The clinical features are characterised by a triad of embolism, intracardiac obstruction and constitutional symptoms. The clinical signs can mimic mitral stenosis and the murmur may vary with body position. Fragments of tumour easily break off but do not grow in its peripheral sites. After complete and careful removal of the tumour recurrence is very rare.

102. A 28-year-old man presents with a 2-year history of increasing dyspnoea with strenuous exertion. Hypertrophic cardiomyopathy is diagnosed. Which is the most appropriate screening method for his brother? Computed tomography (CT) scan Exercise tolerance test Ventilationperfusion scan Echocardiography Genetic screening

Your answer

Hypertrophic cardiomyopathy is usually familial with autosomal dominant transmission. The diagnosis of hypertrophic cardiomyopathy is based upon the demonstration of unexplained myocardial hypertrophy, which is best done using two-dimensional echocardiography. The diagnosis requires that measurements of wall thickness exceed two standard deviations for sex-, age-, and size-matched populations. In practice, in an adult of normal size, the presence of a left ventricular myocardial segment of 1.5 cm or greater in thickness, in the absence of a recognised cause, is usually considered to be diagnostic. Less stringent criteria should be applied to first-degree relatives of an affected individual, where the probability of carrying the disease gene increases from 1:500 to 1:2.

103. A 25-year-old woman is seen in outpatients and is found to have loud first heart sound, an early diastole sound followed by a mid-diastolic murmur. What is the likely diagnosis? Mitral stenosis with a fourth heart sound Mitral stenosis with atrial fibrillation Mitral stenosis with mobile leaflets Mitral stenosis with pulmonary hypertension Mitral valve prolapse

Your answer

From the information given, the diagnosis is mitral stenosis with mobile leaflets. There is no information regarding atrial fibrillation or pulmonary hypertension. Opening snap indicates that the mitral valve is mobile. The snap occurs when the superior systolic bowing of the anterior mitral valve leaflet is rapidly reversed towards the left ventricle in early diastole, due to the high left atrial pressure. S4 is classically late diastolic or presystolic. It occurs when augmented atrial contraction causes presystolic ventricular distension so that the ventricle then contracts with greater force. Atrial myxoma can produce an early diastolic sound (tumour plop), which is due to the abrupt diastolic seating of the tumour within the right or left atrioventricular orifice.

104. A 50-year-old woman is referred to out-patients for a previously asymptomatic atrial septal defect (ASD). She is new to the area and was last seen around 6 years ago in her previous local hospital. She is a smoker but without other significant medical history. She now complains of shortness of breath on exertion, together with peripheral oedema. Clinical examination reveals her to be clubbed and cyanosed. Her pulse rate is 90 bpm and blood pressure 98/60 mmHg. Echo demonstrates a dilated right heart with an estimated right ventricular pressure of 90 mmHg and significant tricuspid and pulmonary regurgitation. What is the likely diagnosis? Cor pulmonale Eisenmengers syndrome Your answer Infective endocarditis

Primary pulmonary hypertension Pulmonary emboli disease

This woman has developed massive irreversible pulmonary hypertension as a consequence of a previous left to right shunt. Pulmonary pressures have now reached systemic level. The reversal of a left to right shunt as a consequence of pulmonary hypertension is known as Eisenmengers syndrome, and is generally the result of a previously undiagnosed ASD, ventricular septal defect (VSD) or patent ductus arteriosus. It may also result from an incompletely corrected Fallots tetralogy or Ebsteins anomaly. Prognosis is poor, although a few patients may be candidates for heartlung transplantation. Symptomatic treatment is directed towards right heart failure. Complications include polycythaemia, bleeding disorders and cerebral embolism or abscess. Since there is a particularly high risk in those of childbearing age, patients should be given appropriate advice and information to avoid pregnancy.

105. A 70-year-old woman is admitted with chest pain and breathlessness. On examination, her heart rate is 170 beats/min. ECG shows atrial fibrillation. What is the next step in her management? Administration of propranolol Administration of verapamil Asynchronous cardioversion Administration of warfarin Immediate heparinisation Your answer The appropriate treatment for atrial fibrillation (AF) is determined by the patients relative risk from the arrhythmia. High-risk patients include those with

a heart rate greater than 150 beats/min, chest pain, an unstable condition or shock. These patients require urgent treatment. Immediate heparinisation, to reduce the risk of systemic embolisation, and attempted cardioversion with synchronised DC shock should be carried out first. Warfarin treatment is indicated in the elderly and those with heart disease. Young patients with lone atrial fibrillation in the absence of heart disease may not need anticoagulation.

106. Which of the following conditions is most likely to produce a wide, relatively fixed split of S2? Congestive cardiac failure Left bundle-branch block Moderate ventricular septal defect Right bundle-branch block and heart failure WolffParkinsonWhite syndrome

Your answer

RBBB makes the split wide and the heart failure fixes the split. (Heart failure does not permit much of a change in ventricular volume with respiration, because breathing with congested lungs is shallow.) Right ventricular failure (RVF) secondary to pulmonary hypertension (PHT) is another condition where you can get a wide fixed split, the wideness of the split being due to a prolonged isovolumetric contraction time in the failing right ventricle. In cases of moderate ventral septal defects, the widening is due to delayed P2, but it is not fixed. In WPW and other causes of electrical delay of LV conduction, including LBBB, there is a narrowly split S2.

107. A young man comes to the A & E Department complaining of feeling unwell and palpitations. Supraventricular tachycardia is confirmed on ECG and he responds to carotid sinus massage. Subsequently, the ECG shows a PR interval of 0.09 sec, widened QRS complex in all leads with a slurred upstroke, dominant R wave in V1 and left axis deviation. What is the most likely diagnosis? Rheumatic fever WolffParkinsonWhite syndrome Atrial fibrillation ASD Right bundle-branch block

Your answer

The ECG features are typical of Wolff-Parkinson-White (WPW) syndrome. This condition is classically associated with a short PR interval (< 0.12 s). Slurring of the QRS complex is due to an extra wave called a delta wave. As the AV node and bypass tract have different conduction speeds and refractory periods, a re-entry circuit can develop, causing paroxysms of tachycardia. Carotid sinus massage or intravenous adenosine will often terminate an episode of this form of tachycardia. One of the features of myocarditis due to rheumatic fever is a prolonged PR interval. This occurs due to a first- or second-degree block. In atrial fibrillation, the ECG shows normal but irregular QRS complexes; there are no P waves but the baseline may show irregular fibrillation waves. A right bundle-branch block presents with wide QRS complexes, dominant R in lead V1, inverted T waves in V1 V4 and a deep wide S wave in lead V6. Atrial septal defects are usually associated with a right bundle-branch block. This leads to an rSR pattern

108. A 50-year-old woman who is already on ramipril, frusemide and atenolol for heart failure, decompensates and presents to A&E with pulmonary oedema. Her heart rate is 120 bpm and her blood pressure is 100/65 mmHg. She is given oxygen and diamorphine. Which of the following actions is indicated in her further management? Increase diuretics and maintain the current dose of -blocker Increase diuretics, reduce the -blocker dose Increase diuretics, increase the -blocker dose Increase diuretics, stop -blockers and later increase the -blocker dose when her lungs are dry Increase diuretics, stop -blockers and restart -blockers when her lungs are dry Although -blockers are not started for the first time in a patient with pulmonary oedema, in a case like this, when the patient is already on -blockers, it is wise to carry on with the same dose. Your answer

109. A 72-year-old man was discharged following successful prosthetic aortic valve replacement. Apart from a small Venflon abscess, which healed with appropriate dressings and cannula removal, his progress had been unremarkable. Now, some 6 weeks later, he is brought to A&E by his wife, suffering from malaise, fever and night sweats. On examination you can hear the murmur of his prosthetic heart valve. Blood testing reveals mild anaemia and raised ESR. Transoesophageal echocardiography suggests the possibility of vegetations. Which of the following regimens is the most appropriate initial choice of antibiotic therapy?

Intravenous penicillin therapy Intravenous gentamicin therapy Intravenous penicillin and gentamicin Intravenous vancomycin, rifampicin and gentamicin Your answer Intravenous gentamicin and vancomycin The choice of antibiotics to treat endocarditis should be guided by local policy, but in the case of possible prosthetic valve endocarditis, regime D is the most appropriate. Regime C is the most appropriate initial therapy for non-prosthetic valve endocarditis. Early prosthetic valve endocarditis is usually caused by Staphylococcus epidermidis, occurring during the first 2 months postvalve replacement, other causative organisms include Staphylococcus aureus, Gram-negative bacilli, diphtheroids and Candida species. In patients with prosthetic valves, transthoracic echocardiography is less sensitive than transoesophageal echo for detecting valve abnormalities. Unfortunately medical therapy is rarely successful in prosthetic valve endocarditis, and surgical valve replacement under antibiotic cover is usually required.

110. A 72-year-old woman presents with two syncopal episodes, and is brought to the Emergency department by her daughter. The second episode has occurred on a particularly hot day after a family walk. She has a past history of hypertension and takes bendrofluazide. On admission to Emergency her blood pressure is 160/125 mmHg and there is an ejection systolic murmur on auscultation of her chest that radiates to the carotids. What diagnosis best fits with this clinical picture? Mitral regurgitation Hypertrophic cardiomyopathy Aortic stenosis Your answer Acute arrhythmia Dehydration due to diuretic use Aortic stenosis causes left ventricular outflow obstruction, which is manifest by a rough ejection systolic murmur, best heard at the base of the heart, and transmitted to the carotids. As aortic stenosis becomes more severe, the sound of aortic valve closure begins to diminish in intensity. There is associated left ventricular hypertrophy, with narrowing of the pulse pressure in the later stages of aortic stenosis. Symptoms commonly appear when the valve orifice decreases to less than 1 cm squared (normal orifice is 3 cm squared). Stenosis is considered severe when the orifice is less than 0.5 cm squared or the pressure gradient across the valve is 50 mmHg or greater. Symptoms of aortic stenosis include angina, syncope (particularly exertional) and congestive heart failure. GI bleeding may occur, as there is an association between aortic stenosis and haemorrhagic telangiectasia.

Investigations of choice are chest x-ray and Echocardiography, with cardiac catheterisation in symptomatic patients to assess the gradient across the valve. Surgical valve replacement is the treatment of choice in appropriate patients.

111. An Asian boy with a known history of rheumatic heart disease presents with lowgrade fever for the past month. He received a course of antibiotics from his GP a week ago. Which of the following investigations would be most useful in the diagnosis? Blood culture Serological testing Echocardiogram C-reactive protein Full blood count

Your answer

Echocardiography is extremely useful in allowing vegetations in infective endocarditis to be seen. Although blood cultures are a key diagnostic test in this condition, they may be negative if patients have recently received antibiotic therapy. The same reasoning applies to serological tests for Coxiella, Bartonella, Legionella, Chlamydia and Brucella spp that may also cause infective endocarditis. Both CRP and polymorphonuclear leucocytosis are nonspecific tests.

112. A 38-year-old woman is seen in A&E with a history of collapse. She recalls rushing for the bus before feeling faint. Her brother recently died suddenly due to a heart problem. On examination she has a jerky pulse, a thrusting cardiac impulse and a mid-systolic murmur. What is the likely diagnosis? Dilated cardiomyopathy Hypertrophic cardiomyopathy Mitral valve prolapse Aortic stenosis Pericarditis

Your answer

Hypertrophic cardiomyopathy (HCM) is the commonest form of cardiomyopathy, with a prevalence of about 100 per 100,000. It is a genetic disorder with autosomal-dominant transmission, a high degree of penetrance and variable expression. Symptoms and signs are similar to those of aortic stenosis, except that the character of the pulse in HCM is jerky. The age of the patient and her family history make HCM the likely diagnosis.

Sudden death can be a presenting symptom. It typically occurs during or just after vigorous physical activity. Risk factors for sudden death in HCM are: a history of previous cardiac arrest or sustained ventricular tachycardia recurrent syncope an adverse genotype and/or family history exercise-induced hypotension multiple episodes of non-sustained ventricular tachycardia on ambulatory ECG a marked increase in the thickness of the left ventricular wall

113. An 18-year-old man with Marfans syndrome is reviewed in the cardiology clinic. Which cardiac abnormality is most likely to be found? Aortic regurgitation Atrial septal defect Dilated cardiomyopathy Mitral valve prolapse Persistent ductus arteriosus Your answer

Marfans syndrome is characteristically associated with progressive aortic root dilatation leading to aortic regurgitation and an increased risk of dissection. Other skeletal manifestations include tall stature, scoliosis, chest wall malformations, high arched palate and lens dislocation. Mitral valve prolapse is also common but there is no association with other congenital malformations or cardiomyopathy.

114. A 16-year-old young man had a cardiac arrest while playing football and was resuscitated. He recovered fully and was later found to have HOCM (hypertrophic obstructive cardiomyopathy). Which is the best treatment option? Implantable cardioverter defibrillator Amiodarone -Blockers Verapamil Rate-responsive, dual-chamber pacemaker Your answer

For the secondary prevention of sudden cardiac death (SCD) in patients with HOCM, there is evidence and general agreement that ICD is the most useful option. Even for the primary prevention of SCD in HOCM, the weight of evidence is currently in favour of its efficacy, although in selected patients amiodarone has a role. Options C, D and E are not considered effective in preventing SCD in HOCM.

115. Which of the following pharmacological agents is most likely to benefit a patient with angina due to syndrome X? Aspirin Bisoprolol Diazepam Diltiazem Isosorbide mononitrate

Your answer

Nitrates are often effective in patients with syndrome X. Cardiac syndrome X consists of angina-like chest pain during exertion, characteristic ECG changes during exercise testing, normal coronary arteries on cardiac catheterisation and no inducible coronary artery spasm during catheterisation. It should not be confused with the metabolic syndrome X, which comprises central obesity, glucose intolerance, dyslipidaemia, and high blood pressure. The dyslipidaemia in this case is primarily high triglycerides and low HDL cholesterol. People with metabolic syndrome are at increased risk of coronary artery disease.

116. A 75-year-old male patient with type-2 diabetes mellitus is brought to A&E complaining of chest pain. He was discharged 2 days ago after an uneventful hospital course following an acute MI 1 weeks previously, having been successfully thrombolysed with streptokinase. An ECG in A&E shows ST elevations in leads V1V3. The patient has been given 10 U reteplase iv. Which of the following statements is correct regarding the further management of this patient? The dose of reteplase should not be repeated Streptokinase would have been a better choice in this situation Antithrombins like heparin should not be administered with reteplase Clinical trials show that streptokinase gives the maximum thrombolytic patency rates The thrombolytic agent associated with the minimum risk of haemorrhagic stroke is streptokinase

Your answer

The thrombolytic agents approved for use in the UK by the National Institute of Clinical Excellence (NICE) are streptokinase, reteplase, tenecteplase and alteplase. Streptokinase is given as an iv infusion over 1 hour. Tenecteplase is given as a single bolus injection. Reteplase is given as two iv boluses 30 minutes apart. Alteplase is given either as an accelerated regimen (one bolus followed by two iv infusions) or as a standard regimen (one bolus and five infusions). If streptokinase had been given more than 5 days ago, neutralising antibodies may prevent the efficacy of a second dose and another agent should be used. Clinical trials have shown that the maximum 90-minute patency rate is obtained with reteplase. Most trials have shown no significant difference in mortality rates between the various thrombolytic agents. However, GUSTO 1 showed that the accelerated alteplase regimen was superior to streptokinase. ASSENT 2 found almost equal 30-day mortality rates associated with the tenecteplase and accelerated alteplase regimens. Thus accelerated alteplase and tenecteplase are believed to be superior to streptokinase. The thrombolytic agent with the minimum risk of causing haemorrhagic stroke is streptokinase. Heparin is co-administered with reteplase and alteplase, but not with streptokinase.

117. You review a 68-year-old woman who presents with a sudden episode of collapse while taking communion in church. This has been her third syncopal episode. Past medical history of note includes recently diagnosed severe hypertension, for which her GP has commenced enalapril therapy. On examination her blood pressure is 160/130 mmHg, she has left ventricular hypertrophy on clinical examination and a loud ejection systolic murmur. Auscultation of the chest reveals bibasilar crackles consistent with mild heart failure. Which of the following is the definitive investigation of choice for this patient? Chest X-ray Electrocardiogram (ECG) Echocardiogram Cardiac catheterisation 24 h holter monitor

Your answer

This patient is suffering from symptomatic aortic stenosis as evidenced by the history of syncope, hypertension, left ventricular hypertrophy and harsh ejection systolic murmur. While echocardiography will aid in diagnosis, gradient across the aortic valve may be underestimated because of the possibility of multiple echo signals and co-existent left ventricular dysfunction. As such cardiac catheterisation is the definitive investigation as it allows for more accurate estimation of valve gradient and characterisation of co-existent coronary artery disease, which may require intervention at the same time.

118. Which enzyme synthesises phosphodiester bonds as part of DNA replication, repair and recombination processes? DNA gyrase DNA ligase Your answer DNA polymerase DNA photolyase DNA glycolyase DNA ligase synthesises phosphodiester bonds. DNA gyrase is a type-2 topoisomerase of Escherichia coli. DNA polymerase synthesises DNA on a DNA/RNA template. DNA photolyase is a bacterial enzyme involved in photoreactivation repair. DNA glycolyase takes part in base excision and mismatch repair processes.

119. A 72-year-old man presents with 15 min of central crushing chest pain. ECG shows 0.5 mm ST elevation in leads V1 and V2. You are in a peripheral hospital with no acute cardiac catheterisation lab. What is the most appropriate treatment? Accelerated tissue plasminogen activator (tPA) + aspirin Aspirin + heparin and repeat electrocardiogram (ECG) in 15 min Heparin only No treatment and repeat ECG in 15 min Streptokinase + aspirin

Your answer

The criteria for thrombolysis are 1 mm ST elevation in two or more limb leads or 2 mm ST elevation in adjacent chest leads, so thrombolysis is not indicated here. However, in the context of a good history of cardiac pain and borderline ECG, an acute coronary event should be strongly suspected and aspirin and heparin given prophylactically, with a repeat ECG in 15 min.

120. A 22-year-old student is admitted by ambulance from a local night club. He has no previous medical history of note and is adopted so is unaware of his family history. Bystanders who have accompanied him say that he suffered sudden collapse while dancing. Bouncers at the club claim that they couldnt feel a strong pulse during his period of unconsciousness. On admission his blood pressure is 120/60 mmHg, and pulse is 80 bpm and regular. ECG looks normal, corrected QT interval is 0.6 s. What diagnosis fits best with his clinical picture?

Simple syncope Long QT syndrome mutation uncharacterised Your answer Ecstasy overdose Carotid sinus syndrome JervellLange-Nielsen (JLN) syndrome This mans QT interval is prolonged. JLN syndrome is also associated with long QT, but patients have deafness in addition to the cardiac rhythm abnormality. Episodes of severe QT prolongation and torsades de pointes ventricular tachycardia in congenital long QT syndrome may be precipitated by increased adrenergic drive (such as that from dancing in a night club). This patient is adopted, so that it may be possible that there is an unknown family history of sudden death. The molecular biology of long QT syndromes is heterogeneous, and a number of different mutations coding for potassium or sodium channels may be responsible. Where specific mutations are identified, antiarrhythmic therapy may be specifically targeted to provide optimum therapy. In patients who respond poorly to medical treatment, implantable defibrillator may be considered.

121. A 60-year-old man suffered an anterior myocardial infarction. He had all the risk factors for coronary artery disease. Which of the following nonpharmacological interventions will be most helpful in reducing his risk of a future ischaemic event? AF duration less than 6 months prior to cardioversion Diet control Regular exercise Stopping smoking Your answer Weight reduction All these interventions are effective but stopping smoking is the single most effective, non-pharmacological intervention that will help to reduce the risk of a future event. There are trials showing that smoking cessation is as effective as having a coronary artery bypass graft.

122. An 18-year-old young man presents to A&E having developed palpitations while playing football. ECG shows rapid atrial fibrillation with a ventricular rate of around 250 bpm. QRS duration is prolonged at around 130 ms. DC cardioversion is performed. Subsequent ECG in sinus rhythm demonstrates a PR interval of 100 ms, positive R wave in V1 and the presence of a delta wave. What further treatment would you recommend? Atrial defibrillator implantation Intravenous and then oral loading with amiodarone Radiofrequency ablation of the accessory pathway Your answer Radiofrequency ablation of the AV node Surgical ablation of the accessory pathway This young man has WolffParkinsonWhite (WPW) syndrome. The most common arrhythmia is an atrioventricular re-entry tachycardia (AVRT). This is a narrow complex with anterograde conduction through the AV node and retrograde conduction via the accessory pathway. Patients who develop AF are at risk of rapid anterograde conduction to the ventricles via the accessory pathway, and this may subsequently degenerate to VF. The extremely rapid conduction with broad QRS duration is typical of this complication. Radiofrequency ablation of the accessory pathway is recommended in this setting and is potentially curative.

123. A 58-year-old man is having his drug therapy reviewed following a myocardial infarction. Which of the following has no proven benefit on mortality following myocardial infarction (MI)?

Atorvastatin Isosorbide mononitrate Ramipril Timolol Tirofiban

Your answer

The glycoprotein IIb/IIIa antagonist tirofiban (PRISM-PLUS), timolol (TIMI trials) and ramipril (AIRE) have all been shown to reduce mortality following myocardial infarction. The recent MIRACL study showed that atorvastatin reduced cardiovascular events by 17% when given for three months post-MI. Isosorbide mononitrate showed no benefit in the ISIS 4 study.

124. Right ventricular myocardial infarction is characterised by which of the following? ST-segment elevation in leads II, III and aVF with Q waves and Twave inversion in these leads Occlusion of the left coronary artery Marked pulmonary vascular congestion A rise in systolic blood pressure Absent Kussmauls sign Right ventricular myocardial infarction usually occurs in association with an inferior-wall left ventricular infarction, as revealed by the ECG. There is usually a right coronary occlusion. Characteristic clinical features include a low cardiac output syndrome with jugular venous distension but no pulmonary vascular congestion. Kussmauls sign (increased jugular venous distension with inspiration) may be evident. Your answer

125. A 54-year-old man is 48-h postmyocardial infarction. You are asked to review him as he is suffering worsening cardiac failure. On examination he has a pansystolic murmur,

loudest at the apex. What complication of his myocardial infarction is most likely to have occurred? Ventricular septal defect Atrial septal defect Acute mitral regurgitation Your answer Acute pulmonary regurgitation Ventricular rupture Acute mitral regurgitation associated with myocardial infarction may occur due to ruptured chordae tendineae. Other causes of mitral regurgitation include papillary muscle dysfunction, infective endocarditis, rheumatic heart disease, idiopathic myxomatous valve degeneration, left atrial myxoma, systemic lupus erythematosus (SLE) and drugs (fenfluramine and dexfenfluramine). The investigation of choice is echocardiography, which may identify left atrial and left ventricular dilatation and confirm the diagnosis of chordae tendineae rupture. Mitral regurgitation associated with chordal rupture in MI may be catastrophic and require emergency surgery for valve replacement. Acute medical management involves treatment with angiotensin-converting enzyme (ACE) inhibition, diuretic therapy and possible anticoagulation. The prognosis for patients with mitral regurgitation is generally good, except in the post-MI situation.

126. A 30-year-old woman presents with a three month history of chest pain. On auscultation, there is a midsystolic click and a late systolic murmur. Her electrocardiogram shows T-wave inversions in leads II, III, and aVF. Which of the following statements concerning her condition is true? The womans chest pain could be due to associated coronary artery disease The click and murmur is likely to occur earlier in systole when the patient stands Your answer An exercise stress test would most likely be positive Asymmetrical hypertrophy of the interventricular septum is revealed on echocardiography Prophylactic measures to prevent subacute bacterial endocarditis are not warranted

The systolic click-murmur syndrome is associated with mitral valve prolapse. It occurs in approximately 4% of the normal asymptomatic population. It can place excessive stress on the papillary muscles and lead to ischaemia and chest pain. Although often associated with inferior Twave changes, the systolic click-murmur syndrome only occasionally results in an ischaemic response to exercise. On standing or during the Valsalva manoeuvre, as ventricular volume gets smaller, the click and murmur move earlier in systole. Echocardiography reveals midsystolic prolapse of the posterior mitral leaflet or, on occasion, both mitral leaflets into the left atrium. Asymmetrical hypertrophy of the interventricular septum is a feature of hypertrophic obstructive cardiomyopathy (HOCM). Infective endocarditis prophylaxis is necessary for those patients with a murmur; an isolated mid-systolic click does not merit them.

127. A 44-year-old man presents with a 2-hour history of severe central chest pain. ECG shows ST elevation in the anterior leads. He was recently discharged following a laparotomy for intestinal obstruction. What would be the best line of treatment for him? Aspirin and clopidogrel Streptokinase Coronary angioplasty Your answer Intravenous heparin Alteplase The symptoms and investigations suggest an acute anterior myocardial infarction. Although thrombolysis would be the normal course of treatment, it would have to be deferred in this case because of his recent major surgery. Aspirin and heparin are not as effective as thrombolysis or angioplasty. The

safest and most effective line of treatment would therefore be to perform coronary angioplasty.

128. A 78-year-old-man presents to Casualty with a history of syncope. An ECG shows complete heart block. Which of the following physical signs is consistent with the diagnosis? Regular cannon a waves on JVP Soft first heart sound Low-volume pulse Basal systolic murmur Loud second heart sound

Your answer

Complete heart block produces a slow regular pulse (2550/min) that doesnt vary with exercise. Usually, there is a compensatory increase in stroke volume with a large-volume pulse and systolic flow murmurs. Cannon a waves are irregularly seen, and the intensity of the first and second heart sound varies due to the loss of atrioventricular synchrony.

129. A 40-year-old woman presents with a 3-month history of fatigue, weight loss, night sweats and a degree of exertional dyspnoea. Her past history includes a prosthetic mitral valve replacement 2.5 years ago. She is pyrexial with evidence of mitral regurgitation and splinter haemorrhages. Echo confirms moderate paravalvular mitral regurgitation. Blood cultures are taken and a diagnosis of infective endocarditis made. What is the most likely infecting organism in this case? Coxiella burnetii Enterococcus spp Staphylococcus aureus

Staphylococcus epidermidis Streptococcus viridans Your answer The commonest infective cause of native valve endocarditis in the UK is still Strep. viridans, accounting for around 40% of all cases. Enterococcus spp accounts for approximately 10% of cases and is more prevalent in the elderly. Staph. spp account for around 25% of cases of endocarditis. In the first year following prosthetic valve replacement the spectrum of infecting organisms is somewhat different, with coagulase-negative staphylococci being the most common (around 50%). The majority of these are Staph. epidermidis. After the first year following valvular surgery the spectrum of infecting organisms is very similar to that for native valve endocarditis.

130. A 25-year-old man presents to the emergency department with a 1-week history of fever and myalgia. He had travelled to Chile 8 weeks ago. On examination there are no positive findings, although the patient recollects that his right eyelid was swollen for a few weeks after he left Chile. ECG reveals nonspecific, T-wave changes in all leads. What is the most likely diagnosis? Echinococcosis Falciparum malaria Schistosomiasis Toxoplasmosis Trypanosomiasis Your answer Trypanosoma cruzi. causes American trypanosomiasis or Chagas disease and is quite common in South America. The vectors are reduvid bugs. The trypanosomes are transmitted by scratching infected faeces of the bug into skin

abrasions caused by the bug during blood sucking. In acute trypanosomiasis, the patient presents with fever, myalgia, hepatosplenomegaly and myocarditis. Unilateral periorbital oedema and swelling of the eyelid can result from a bug bite around the eyes. This is called Romanas sign. The other conditions listed can cause myocarditis, but the best choice is trypanosomiasis.

131. Which of the following best describes the mechanism of action of flecainide as an antiarrhythmic agent? Slows the upstroke of the action potential Your answer Increases the action-potential duration Has a direct membrane effect Increases vagal tone Affects SA and AV nodes

Flecainide, a class Ic agent slows the upstroke of the action potential and is its main mechanism of action. It has minimal effects on action-potential duration. In other words, it causes a marked decrease in conductivity, with little effect on refractoriness. The antiarrhythmic group that mainly affects sinoatrial and atrioventricular nodes, and thus has a direct membrane effect, is the calciumchannel blockers. Class V agents (digitalis agents) affect SA and AV nodes by increasing vagal tone.

132. Urinary hesitancy as a sign of drug-induced toxicity is characteristic of which of the following antiarrhythmics? Amiodarone Sotalol

Disopyramide Your answer Flecainide Verapamil Amiodarone causes hepatic effects, peripheral neuropathy, proximal myopathy, thyroid dysfunction, skin discoloration and pneumonitis, among others. Sotalol (-blockers) and flecainide have negative inotropy and CNS effects. Verapamil causes bradycardia.

133. A 67-year-old man with chronic heart failure is reviewed in terms of his drug therapy. Which of the following treatments has no proven mortality benefit? Bisoprolol Digoxin Enalapril Nitrates and hydralazine Spironolactone

Your answer

Bisoprolol (CIBIS II), spironolactone (RALES), enalapril (CONSENSUS) and nitrates and hydralazine (V-HEFT) have all been shown to improve mortality in chronic heart failure. Digoxin reduces the risk of death due to heart failure but overall cardiovascular mortality is similar to that on placebo, probably reflecting a small increase in the risk of arrhythmic death with digoxin therapy.

134. A patient with left ventricular failure undergoes echocardiography. Which is the correct formula for calculating the ejection fraction (EF)? EF = end diastolic volume (EDV) end-systolic volume (ESV)/EDV EF = end diastolic volume (EDV) end-systolic volume (ESV)/heart rate (HR) Your answer

EF = heart rate (HR) end diastolic volume (EDV)/end-systolic volume (ESV) EF = heart rate (HR) end-systolic volume (ESV)/end diastolic volume (EDV) EF = end-systolic volume (ESV) end diastolic volume (EDV)/EDV Ejection fraction (EF) is calculated using the following equation: EF = (end diastolic volume [EDV] - end-systolic volume [ESV]) / EDV

135. A 55-year-old man who has sustained an acute MI subsequently presents with heart failure. As well as other treatments the cardiologist has recommended that abeta-blocker be commenced. According to currently available evidence which of the following betablockers would be most appropriate? Celiprolol Labetalol Bisoprolol Propranolol Sotalol

Your answer

Beta-blockers may produce benefit in heart failure by blocking sympathetic activity. Bisoprolol and carvedilol reduce mortality in any grade of stable heart failure. Treatment should be initiated by those experienced in the management of heart failure. According to currently available evidence (see NICE guidelines on cardiac failure, 2003), bisoprolol, metoprolol sustained release and carvedilol have shown the most useful effects. At present metoprolol is not licensed in the UK for this indication and so carvedilol or bisoprolol are the preferred choices.

136. A 38-year-old man of Chinese descent who smokes 60 cigarettes per day presents to his GP. He is developing pain at rest in his legs, and is unable to walk more than a few yards due to ischaemic pain. On examination there is prolonged capillary refill and necrotic ulcers at the tips of his toes. There is also evidence of thrombophlebitis. What diagnosis fits best with this clinical picture? Buergers disease Simple peripheral vascular disease Polyarteritis nodosa Familial hypercholesterolaemia Your answer

Temporal arteritis Buergers disease (thromboangiitis obliterans) is an occlusive inflammatory disease of smallto medium-sized arteries of the upper and lower extremities. Histopathology examination of affected arteries reveals fresh inflammatory thrombus within both small- and medium-sized arteries and veins, with giant cells surrounding the thrombus. The disease is very closely associated with heavy smoking; continued smoking after diagnosis invariably leads to a poor outlook, gangrene and multiple amputations. Prevalence is higher in men and people of FarEastern origin. The main goal of therapy is elimination of tobacco smoking. Bypass surgery is of variable success due to the distal nature of the occlusions. Sympathectomy may be useful in increasing distal blood flow and relieving pain. Amputation of gangrenous digits is frequently required.

137. A 17-year-old youth is brought to the GP by his mother. He was previously seen 2 weeks earlier suffering from acute pharyngitis. His teeth are in generally poor condition, but otherwise there is no previous medical history. On examination he is febrile with a temperature of 38.2 C, and has a polyarthritis affecting his knees, ankles, wrists and elbows. He also appears to have subcutaneous nodules over his elbows, and mitral regurgitation on cardiovascular examination. What diagnosis fits best with this clinical picture? Bacterial endocarditis Juvenile rheumatoid arthritis Scarlet fever Rheumatic fever Your answer Congenital valvular heart disease This patients clinical condition is highly suggestive of rheumatic fever. Physical findings suggestive of rheumatic fever include the history of previous pharyngitis, fever, polyarthritis, carditis (including the mitral regurgitation murmur) and the presence of subcutaneous extensor surface nodules. Laboratory testing suggestive of the diagnosis would include a positive anti-streptolysin O titre (peaks at 45 weeks after a streptococcal throat infection), raised erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and a leucocytosis is also suggestive of rheumatic fever. Acute treatment includes a course of penicillin to eradicate throat carriage of group A streptococci; where there is carditis or arthritis, aspirin or prednisolone may be added, but specialist advice is advised. Erythromycin may be used in penicillin-allergic patients.

138. A 30-year-old man presents complaining of wheezing and loose motions. On examination he has prominent precordial pulsations. What is the most likely diagnosis?

Carcinoid heart disease Congenital tricuspid regurgitation HIV-associated heart disease Rheumatic heart disease Traumatic heart disease

Your answer

Carcinoid heart disease occurs when there is an accumulation of fibrous tissue in the heart, especially to the undersurface of the tricuspid valve. It can hold the tricuspid valve in a semiclosed position, so tricuspid stenosis and regurgitation can occur. If it affects the pulmonary valve, pulmonary regurgitation or stenosis occurs. It is usually associated with carcinoid tumour of the bowel and with liver metastases. Bronchospasm, diarrhoea and flushing are part of the carcinoid syndrome. Traumatic tricuspid regurgitation can occur due to ruptured chordae tendinae, but there is no wheezing or diarrhoea. HIV can cause cardiomyopathy, pericardial diseases, myocarditis and heart failure.

139. A patient with an aortic valve replacement develops right hemiparesis. CT scan shows cerebral infarction. There is no evidence of cerebral haemorrhage. The INR is 2.0. How would you manage this case? Reverse the anticoagulation with vitamin K Stop warfarin and start intravenous heparin Increase the dose of warfarin Continue warfarin and add intravenous heparin Decrease the dose of warfarin until the INR is 1.5

Your answer

Use of oral anticoagulation may result in haemorrhage in the infarcted area. As the patient has a mechanical valve, anticoagulation must be continued. The best option therefore would be to stop the warfarin and start intravenous heparin. The reason for this is that heparin can be more easily controlled than oral anticoagulation during the acute period of stroke recovery.

140. A 70-year-old man undergoes successful DC cardioversion for atrial fibrillation (AF). Which one of the following factors best predicts long-term maintenance of sinus rhythm following this procedure? Age under 75 years Normal left ventricular function Warfarin therapy No alcohol intake

AF duration less than 6 months prior to cardioversion

Your answer

Cardioversion has a much higher success rate in patients with structurally normal hearts but the left atrial size is a better predictor than left ventricular function. AF is likely to be persistent where the left atrial dimension is >5 cm. Age is much less important than the duration of AF. The success of cardioversion drops off significantly after 6 months of persistent AF and long-term sinus rhythm is unlikely to be restored if AF has been persistent for more than 12 months. Alcohol is an important aetiological factor but less significant than AF duration. Warfarin is important to reduce stroke risk but does not help to restore or maintain sinus rhythm.

141. A 68-year-old-man with atrial fibrillation (AF) is admitted electively for DC cardioversion, to be performed as a day-case procedure. However, the procedure is postponed to a later date. Which one of the following reasons could be responsible for the delay? He had discontinued digoxin for the last 2 days He was taking amiodarone His INR 3 weeks ago was 1.6 Your answer His serum potassium level was 4.2 mEq/l He had an episode of angina 2 days ago Although the INR on the day of cardioversion is important, the INR should be optimal in the preceding 3-4 weeks prior to cardioversion. External cardioversion is a safe and effective method for restoring sinus rhythm, and should be attempted at least once in every patient with chronic AF. Overt congestive heart failure, hypokalaemia and hypothyroidism should be controlled as much as possible before cardioversion. Acute myocardial infarction is not a contraindication to cardioversion. If the patient has a slow ventricular response of AF in the absence of anti-arrhythmic drugs, cardioversion should be performed after the insertion of a temporary transvenous-pacing catheter. Electrical cardioversion is initially successful in 7094% cases, but relapse is frequent (25 50% at 1 month and 7090% at 1 year). The success depends on the duration of AF, transthoracic impedance, left atrial size and the age of the patient. Digoxin should be withheld on the day of cardioversion. However, if digoxin toxicity is suspected, the problem should be resolved before cardioversion is attempted. Pre-treatment with amiodarone or sotalol may prevent early recurrence. The initial shock strength should be 100 J, followed by a second 200-J shock and a third 360-J shock. If AF persists, a second 360-J shock with the paddles in the anteroposterior position can be attempted. Immediate DC cardioversion, after the administration of intravenous heparin, is appropriate in an emergency or if AF has been present for less than 48 hours. In elective cases, patients should be established on warfarin to give an INR of between 2 and 3 for a minimum of three weeks prior to cardioversion. Anticoagulation

should be continued for four weeks after successful cardioversion.

142. A 50-year-old man presents with a 1-hour history of severe central chest pain. There is no significant past medical history. He is haemodynamically stable with pulse rate of 90 bpm and blood pressure of 120/70 mm Hg. ECG shows 5 mm of ST-segment elevation in the anterior leads (V2V4). He received aspirin 300 mg in the ambulance and 5 mg diamorphine. What would be the next line of treatment? Clopidogrel Enoxaparin GIIb/IIa blocker Streptokinase Tissue plasminogen activator Your answer This relatively young man has presented early with acute anterior myocardial infarction. The key therapeutic aim is early reperfusion in an attempt to save myocardium. In centres with rapid access to primary angioplasty this would be the optimum strategy. However, in the UK this is a rarity and far from the norm. All patients with suspected MI should receive aspirin. In youngish* patients presenting early (within 4 hours) with acute anterior MI, thrombolysis with accelerated tissue plasminogen activator (tPA) should be considered since it is associated with a small benefit in the mortality rate over streptokinase. The downside is the cost; tPA is several times more expensive than streptokinase. *The evidence (GUSTO trial) is for patients less than 55 years of age, male, and within 4 hours but most would agree for patients less than 60 years of age.

143. A 39-year-old female is admitted with pulmonary oedema, blood pressure 230/140 mmHg and fundoscopy showing retinal haemorrhages and papilloedema. She has systemic sclerosis and asthma. Which of the following agents would be the most appropriate immediate management? Intravenous labetalol Intravenous sodium nitroprusside Atenolol Nifedipine oral Your answer Nifedipine sublingual The malignant phase of hypertension is a rare condition characterised by very high blood pressures, with bilateral retinal haemorrhages and/or exudates or cotton wool spots, without the added requirement for papilloedema. All patients with malignant hypertension should be admitted for assessment, investigation, and commencement of therapy under supervision. The initial aim of treatment is to lower the diastolic pressure to about 100105 mmHg over a period of 23 days, with oral therapy and dose escalation at daily intervals if necessary. The maximum initial fall in blood pressure should not exceed 25% of the presenting value. Blood pressure should be measured 4-hourly. The first-line oral antihypertensive agent is either a short-acting calcium antagonist (such as nifedipine) or a blocker (such as atenolol). Beta-blockers are contraindicated in asthma. An appropriate dose of nifedipine is 1020 mg of the tablet formulation, which can be repeated or increased as necessary to bring about gradual reduction in blood pressure. Nifedipine is not absorbed from the oral mucosa, and there have been reports of complications including visual loss, cerebral infarction, and myocardial infarction with nifedipine therapy using the short-acting sublingual capsules. Sublingual nifedipine produces unpredictable falls in blood pressure and should never be used. ACE inhibitors and Angiotensin II receptor antagonist are beneficial in the treatment of renal failure in patients with scleroderma.

144. Which one of the following statements BEST describes primary pulmonary hypertension? The familial form is inherited as sex-linked recessive Chronic thromboembolic disease can be identified in 30% of primary cases Spontaneous remission is the rule in more than half the cases Cannabis inhalation may induce similar disease The risk for subacute bacterial endocarditis is low and antibiotic prophylaxis is seldom required

Your answer

One of the diagnostic criteria includes a mean pulmonary artery pressure of more than 25 mmHg at rest or more than 30 mmHg with exercise. Recurrent thromboembolism is one cause of secondary pulmonary hypertension (not primary). Fenfluramine, cocaine inhalation and HIV infection can cause pulmonary vascular disease with clinical and pathological features similar to those of primary pulmonary hypertension. The familial form is inherited as autosomal dominant. The medium period of survival is two to three years after the diagnosis. Recent improvement in diagnosis and newer forms of treatment have improved survival, but the prognosis is generally very poor and most patients gradually succumb to progressive right-sided heart failure.

145. A 69-year-old man presents with an 8-hour history of chest pain. ECG shows an inferior wall infarction with ST elevation of 3 mm. There is no history of diabetes mellitus, injury or previous surgery. Blood pressure is 132/70 with a pulse of 58. Which of the following treatments would be most appropriate? Tissue plasminogen activator Aspirin Streptokinase Heparin Metoprolol

Your answer

Many large trials have shown that thrombolysis within 12 hours reduces the extent of ventricular damage and the mortality rate. Tissue plasminogen activator (TPA) achieves higher reperfusion rates but may be associated with a higher risk of stroke. TPA tends to be given in preference to streptokinase in patients under 50 years of age with anterior wall myocardial infarctions where the blood pressure is low (systolic < 100 mmHg), and in those patients who have previously received streptokinase. TPA is more effective than streptokinase only if it is administered within 4 hours of the onset of chest pain. Intravenous heparin may be given after the initial thrombolytic therapy though its role is doubtful. Aspirin (300 mg tablet) is usually recommended. Following initiation of

thrombolysis, an intravenous -blocker such as metoprolol is given, especially if the heart rate is > 100 beats per minute with persistent pain. 146. A 30-year-old woman with a previous history of deep vein thrombosis is expecting her first child. During which phase of her pregnancy and puerperium does she have the greatest risk of venous thrombosis? First trimester Second trimester Third trimester During delivery First 6 weeks after delivery

Your answer

There is an increase in thromboembolic complications because of the hypercoagulability that exists postpartum. Anticoagulants may be necessary during pregnancy to prevent or control the following: venous thrombosis, pulmonary embolism, rheumatic mitral valve disease, prosthetic heart valves, peripartum cardiomyopathy, primary pulmonary hypertension and Eisenmengers syndrome.

147. A 40-year-old man is referred by his GP for advice with regard to primary prevention of cardiovascular disease. He is a smoker with a strong family history of premature death from ischaemic heart disease. Following a period of lifestyle modification, his fasting cholesterol concentration is 7.2 mmol/l. On consultation of the local guidelines you find that his estimated 10-year risk of a coronary heart disease event is > 30%. What would you advise? Cholestyramine Dietician advice Fibrate Nicotinic acid Statin Your answer

The National Service Framework for Coronary Heart Disease (2000) and the Joint British Society Guidelines recommend targeting individuals with a 10-year risk of a coronary heart disease event of > 30%. Individuals should be offered interventions to address all modifiable risk factors, including dietary advice, smoking cessation advice and support, moderation of alcohol consumption and weight reduction where appropriate. In respect of lipid management, nonpharmacological and pharmacological interventions should be utilised to achieve a total cholesterol concentration < 5.0 mmol/l and an LDL cholesterol concentration of < 3.0 mmol/l. The results of several important trials support the use of statins in primary prevention, these include: WOSCOPS (pravastatin) AFCAPS/TEXCAPS (LEVASTATIN).

148. A 58-year-old-woman suffers a cardiac arrest while on the ward. A rhythm strip shows VF. What is the strength (in joules) recommended for the monophasic shock used for defibrillation? 50 100 200 300 360 Your answer Three-quarters of arrests are due to ventricular fibrillation. Only a small proportion is due to electromechanical dissociation (EMD), the rest being due to asystole. EMD usually has a potentially reversible cause: hypovolaemia hypoxia hyperkalaemia hypokalaemia hypothermia

tension pneumothorax tamponade toxicity due to drugs thromboembolism

Defibrillation is used to convert VF to sinus rhythm. Previously the recommendation was Initially a monophasic 200-joule shock, followed by 200-J and then 360-J shocks. New resusciation guidelines now recommend shocking at 360-J.

149. Which one of the following features is MOST typical of coarctation of the aorta? The coarctation is proximal to the left subclavian artery origin if the right arm blood pressure is significantly higher than in the left arm Continuous murmur over the thoracic spine usually originates from extensive collaterals Rib notching on plain chest X-ray can be identified as early as three months after birth Atrial septal defect (ASD) is the commonest associated congenital abnormality The risk for subacute bacterial endocarditis is low and antibiotic prophylaxis is seldom required Your answer

The commonest site of discrete obstruction of the aortic lumen is just distal to the origin of the left subclavian artery. The systolic arterial pressure in the arms exceeds that in the leg. If the systolic arterial pressure in the right arm is higher than that of the left arm by more than 30 mmHg, the left subclavian is involved in the coarctation. Continuous murmur over the thoracic spine usually originate from small, tight coarctation (< 2 mm). Other cardiac malformations are frequent, the commonest being a bicuspid aortic valve. Notching of the inferior border of the ribs from collateral vessels is common and usually manifest in adults and older children. Patients with coarctation are at high risk of subacute bacterial endocarditis and should be strongly advised about antibiotic prophylaxis.

150. A 38-year-old man presents for review. His only previous history of note has been recurrent shoulder subluxation. His main complaints are tiredness and increasing dyspnoea

on exertion. The nursing clerking on admission notes that he seems very tall and thin, his height is described as 1.93 m (6ft 4 inches). On examination his blood pressure is 165/70 mmHg, he has left ventricular hypertrophy, a low-pitched apical diastolic murmur and an early systolic apical ejection murmur. What diagnosis fits best with this clinical picture? Mitral stenosis Aortic regurgitation Your answer Mitral valve prolapse Aortic stenosis Infective endocarditis This man has a marfanoid habitus and is at risk of suffering aortic regurgitation. Aetiological factors involved in aortic regurgitation include infective endocarditis, rheumatic heart disease, trauma with valvular rupture, congenital bicuspid aortic valve, myxomatous degeneration, syphilitic aortitis, systemic lupus erythematosus (SLE), aortic dissection and the use of amphetamine slimming products. Symptoms of aortic regurgitation include dyspnoea on exertion, syncope, chest pain and congestive heart failure. Cardiac auscultation characteristically reveals displacement of the cardiac impulse downwards and to the left, prominent S3 heard over the apex, a low-pitched apical diastolic rumble (AustinFlint murmur) and an early systolic apical ejection murmur. Chest X-ray may reveal left ventricular hypertrophy and aortic dilatation. Echocardiography reveals the coarse diastolic fluttering of the anterior mitral valve leaflet. Surgical valve replacement is indicated in symptomatic patients with chronic aortic regurgitation who have symptoms despite optimal medical management, and in acute aortic regurgitation where there is evidence of left ventricular failure. Ideally, surgery should be considered before the ejection fraction falls to below 55%.